“Be Strong My Sista’”: Sentiments of Strength from Black Women with Chronic Pain Living in the Deep South

Abstract

The experience of chronic pain is influenced by gender, race, and age, but is understudied in older Black women. Society and family alike expect Black older women to display superhuman strength and unwavering resilience. This qualitative study examined the narratives of nine rural- and urban-dwelling Black older women to identify the ways in which they displayed strength while living with chronic osteoarthritis pain. Their “herstories” parallel the five characteristics of the Superwoman Schema/Strong Black Woman. Two additional characterizations emerged: spiritual submission for strength and code-switching to suffering Black woman; these may be unique to Black Americans with pain.

While on vacation in Oklahoma in 2016, I [last author] met Ms. Janice McMahon [pseudonym], a 60-year-old Black woman with short natural hair, flawless dark skin, and a beautiful, genuine smile. She wore a light pink t-shirt, floral skirt and pink flip-flops, and I vividly remember wondering if she was a breast cancer survivor because of the pink t-shirt. Nonetheless, unprompted, she began to share with me (and my mom and her close friend) her 17-year experience with chronic pain. She talked about the adverse effects of pain medications, how the body was not designed to be on meds for long-term use, and the feeling of toxicity in her body and not being able to continue in life this way. So she decided to go on a road trip, or as she exclaimed- her “bucket list,” alone. She explained how her “bucket list” trip has been a time of reflecting and becoming closer to God and rejuvenating her health and spirit. As she shared her story in the warm hallway of a casino hotel, she expressed three sentiments of ‘surviving rather than thriving’ that are common in African American culture regarding health and disease: (1) keep quiet and don’t talk about the problem, and (2) be strong, and (3) have faith. She stated that “As African American women, we keep it to ourselves and are expected to be strong,” but that strength is sometimes depleted by the physical and psychological toll of chronic pain. As she talked, my mom whispered to me, “Tell her, tell her. Tell her what you do.” Being the proud mom that she is, she wanted me to share with Ms. Janice my community-informed research on chronic pain with African Americans. I ignored my mom, as I wanted to keep the focus less on me and my work and more on her experience unashamedly. It was clear that sharing her story with us was therapeutic. As she departed, she told me, “take care, my young sista’.” At that moment, we connected, and . I was reminded of a Black gospel song, “May the Work I’ve Done Speak for Me,” because, although I didn’t once share my program of research, it was apparent that my passion, purpose, and career spoke more than my verbal responses. I believe every interpersonal encounter is purposeful– sometimes to teach us and other times to affirm. If anything, I was reminded of how many Black women are suffering in silence and desperately awaiting to share their lived experiences.

“I am not my sister’s keeper. I am my sister.” - Iyanla Vanzant

INTRODUCTION

Chronic pain is linked to several chronic conditions, such as osteoarthritis (OA), and is considered the “invisible disability”^1,2 particularly evident in women with disabilities.³ Published research reveals that gender and sex differences in pain exist such that women and racial minorities experience greater pain and encounter more disparities than non-Hispanic Whites.^4-6 For example, osteoarthritic joint pain prevalence is higher among women and non-Hispanic Blacks.⁷ Older and middle-aged Black women experience a higher risk of pain and pain-related disabilities because they stand at the intersection of sex, age, racial discrimination, and socioeconomic inequities resulting in poor mental and physical health.⁸

A study of 2,400 women with chronic pain found that over 90% reported gender-based discrimination in the healthcare system.⁹ Women suffering from chronic pain may be targeted, stereotyped, and experience gender microaggressions from providers.^2,10 Verbal dominance by health care providers towards Black women has resulted in dismissive attitudes towards reports of pain, diagnostic delays, and treatment bias. These actions contribute to pain-related stressors specific to Black women which are intertwined with feminine expectations historically grounded in racial oppression. Black women have suffered stigmatization and power differentials for decades, during the last century. Since the enslavement era, Black women have had to bear the image of unwavering strength and resilience as a survival mechanism that has seeped into racial and social constructs that are now recognizable in modern culture, scientific research, and healthcare.^11-13

For decades, Black women have been negatively labeled based on unfounded assumptions, colonial hatred, and for comedic exploitation. Mainstream portrayal of Black women include being the mammy caricature (e.g., Aunt Jemima), welfare queen, angry Black woman, and Jezebel (or “hot/fast” woman/whore).¹³ Other stereotypical and offensive labels and names consist of “girl or gal,” “the help,” “divas,” “drama queens,” and “hood chick.” Booker reported that even white, female nurses stereotype or label Black women with chronic pain as “drama queens,” and therefore difficult and their pain dismissed.¹⁴ Labeling women with chronic pain as emotional is a common gender bias and pressuposed gender norm in clinical and research settings.¹⁵ This is quite disappointing given the responsibility of nurses to provide unbiased and ethical pain care to patients.¹⁶ Another label, the “Strong Black Woman” has also been associated with Black women over time.

A culturally-derived,but related framework, the Strong Black Woman (SBW) Script or Archetype^17-19 theorizes and shows unique race- and gender-specific experiences that force a resolute and stoic disposition and the exhibition of an unbreakable strength in Black women. The SBW construct is culturally specific with five traits: (1) maintaining unwavering strength, (2) suppressing emotions, (3) demonstrating self-reliance, (4) succeeding despite obstacles, and (5) placing the need of others before themselves.^13,18 Without the support of family/friends and providers,²⁰ many older Black women have been conditioned to “bear the pain” and continue with life.¹ Recent SBW studies have found adverse mental health outcomes such as decreased emotional support, increased psychological distress, and inadequate coping responses.^21-22 Current literature has focused on profiling the SBW model in areas associated with stress and chronic disease, such as cardiovascular disease,²³ diabetes/pre-diabetes,²⁴ mental health,^21,25-26 breast cancer screening,²⁷ and intimate partner violence.²⁸ Surprisingly, no SBW studies report on the image of strength and living with OA pain among older Black women.

The underlying premise of this paper is that chronic pain is a gendered racial experience that necessitates an ethnic-specific lens. Therefore, the purpose of this secondary qualitative analysis was to investigate how older African Americans display strength (verbal, behavioral, cognitive) while living with OA. The novelty of this study is that it uses the SBW framework to parallel and explain the distinct experience of older Black women living with chronic pain with the impression or expectation of being stoic. To this end, this analysis allows the female/woman participants to tell “herstories of strength” while living with chronic OA pain.

THEORETICAL FRAMEWORK

Several pain theories explain the biological process of pain, but few extend into the psychosocial and cultural aspects of pain (e.g., Biopsychosocial Model of Pain;²⁹ Biocultural Model³⁰), especially in ethnic minority populations. As written by Morris, “…pain is never the sole creation of our anatomy and physiology. It emerges only at the intersection of bodies, minds, and cultures”.^31(p3) This supports a growing need for discourse on culturally-relevant theories and frameworks that can address the distinct health-related behaviors and mechanisms that lead to disparities in pain when misunderstood or unappreciated. There is a strong incommensurability of superimposing traditional theories on a marginalized population with specific and unique needs. Doing so may contribute to perceived injustice in pain by homogenizing the experience of pain across racial and gender groups. Hence, the first-hand narratives of older Black Americans compel a look at the explicit and implicit links between emotions, behaviors, and cognition that contribute to their exudence of strength or potentially lack thereof.

Understanding the social and health facets that largely promote or limit successful aging in Blacks requires a conceptually relevant lens, one that is more culturally salient and can appositely contextualize the emotional, spiritual, and psychological dynamics of chronic pain in older Black women. Black women with cancer pain noted that Black culture teaches us to be strong women for our families and communities.³² Baker et al. proposed using the SBW archetype in reconceptualizing aging in African American/Black women on the basis that unique social indicators of health, mental and physical health factors, and historical experiences influence aging health, and health outcomes.³³ Thus, this culturally-centered framework may help elucidate and appreciate the experiences and characteristics (e.g., self-reliance, independence, emotional restraint and emotional intelligence, maternalistic reciprocity) of Black older women.

“This Strong Black Woman is a cultural icon born of black women’s resilience in the face of systemic oppression that has dismantled families and made economic stability a formidable challenge”.^{34(no page)} The SBW is a “cultural ideal that reflects an expectation that black women be selfless, self-reliant, psychologically and physically strong, and resilient despite the many social challenges” (e.g., racism, sexism, ageism, colorism, and able-ism).^33(p52) The SBW is both a stereotype and a ‘sainted’ figure in Black culture that is accompanied by benefits (e.g., admiration, positive coping) and baggage (e.g., stress, suffering). This is not a mutually exclusive concept, rather, can be viewed as both a positive and negative state of mind depending on the person or circumstance; the operationalization of this concept is relative to how a Black woman negotiates and navigates life. More importantly, the SBW theory decolonizes American or Euro-centric conceptions of strength and highlights the distinct particularities of Black Women— who are considered, as spoken by Malcom X, the most disrespected, unprotected, and neglected person in America³⁵ despite her dedication as a “…provider, caretaker and homemaker. And often, she is suffering”. ^{34(no page)}

METHODS

Design

Methodological procedures and rigor of the parent study have been thoroughly addressed in several publications; the parent study investigated the experience of and strateiges for managing OA pain in African Americans older adults.^1,36 This secondary data analysis uses a descriptive phenomenological approach to apply the SBW lens to capture the lived experience of older Black women. This work was supported in part by the National Hartford Center of Gerontological Nursing Excellence and the National Institute of Nursing Research.

Ethical Compliance

The study was rigorously reviewed and granted approval by the Institutional Review Board (IRB) at the University of Iowa. All participants were provided an approved study information sheet about the study’s purpose, human subjects protections and rights, risks and benefits, and study’s contact information. Oral informed consent was provided by all participants to complete surveys and interviews. Strict confidentiality and privacy were maintained where access to data was limited to relevant study staff and transcribers. Paper-based surveys and audio files were kept secured, and electronic research documents were stored on an institutional password-protected server.

Sample

Following IRB approval, a convenience sample driven by community-engaged and snowball sampling techniques, resulted in 110 self-identifying African American/Black women and men completing the study. Study eligibility criteria are published.³⁶ Participants lived in the southwestern United States and were between 50-94 years of age (midlife and older adults). The principal investigator (PI; i.e., last author) used self-reported demographic data (e.g., age group, education attainment level, pain severity) to purposively identify participants for qualitative interviews.³⁶ We attempted contact with 21 individuals, and 18 agreed to be interviewed.

Data Collection

Two visits were conducted with participants, first to complete cross-sectional surveys and the second for in-depth, individual interviews at safe and quiet locations. For the both phases, the PI met all participants at their home or business, and for personal safety reasons of going into unfamiliar communities, a second person was notified of the general geographic proximity of the research visit; this was not because Black communities were presumed unsafe. Individual interviews serve as the primary data source for this sub-study, and demographic and pain surveys provide descriptive data. Interview conversations were captured using a digital recorder. The interviews flowed from open-ended questions from a semi-structured interview guide designed to understand the personal, cultural, and community perspectives of managing osteoarthritis pain. Written field notes were used to capture key statements or ideas of participants, the meanings ascribed to issues, and the internal reaction and thoughts of the PI.

Analytic Plan

A planned, systematic process guided qualitative data analysis: ensuring audible recordings, accurate audio transcription, immersion in the interview data, iterative and collaborative development of categories/concepts, codes, themes, and culturally congruent interpretations.¹ Transcripts were uploaded into HyperRESEARCH qualitative data management software for analysis. The PI and a then postdoc fellow (first author), both with expertise in African American health, independently re-analyzed original codes, focusing specifically on codes and transcript texts which related to strength and resilience. For the purpose of this analysis, we applied the SBW framework by identifying text that aligned with each of the five tenets while also yielding to the emergence of additional characterizations of the SBW. Codes were then compared to assure that the findings are trustworthy and confirmable. A long list of codes was sorted, collated based on theoretical or practical similarity, and examined for broad patterns and themes. Relationships between codes and themes were identified, and a visual hierarchy of themes and sub-themes was created for the parent study. An expert investigator and advanced practice nurse in women’s health (second author) then reviewed our codes and results and cross-referenced interpretations to identify any biases and unfounded conclusions; no further discrepancies in coding were noted.

Rigor

Several steps were taken to conduct an authentic and credible study, and the PI placed great emphasis on allowing the participants to share their life stories. Prior to the study’s initiation, content experts in geriatric pain and qualitative methods worked closely in the conceptualization and development of the research protocol and interview guide. Given the unique linguistic and southern dialect of participants, transcription accuracy was ensured through independent verification of all interviews by the PI. Further, qualitative transcripts were cleaned by eliminating (potentially) identifying information and clarifying participant responses labeled as inaudible or cross-talk by the transcriptionists. The PI maintained an audit trail that chronicled all methodological and analytic decisions. All data (raw and transcribed), data analysis, and visual representations of the findings were retained for the audit trail. Reflexive techniques were applied before study commencement and during qualitative interviews to critically identify the PI’s assumptions and biases about the world, research, participants, and their life realities. For example, a priori bracketed assumptions included:

• Older African Americans in northern Louisiana would have limited experience with research participation and would therefore exhibit low research literacy or interest.

• Spirituality and religiosity would be a driving force in most dimensions of African American life, including managing chronic diseases such as OA.

• Participants would view the PI, an African American, as an “outside-insider” due to demographic and socioeconomic differences (e.g., advanced education, young age, healthcare provider) and may influence level of trust, receptivity, and responsiveness in interviews. In addition, to further understand and bracket participants’ potential biases, they were asked to identify their motivation for participating in the research study.

Epistemological Position and Intersectional Identity

The methodological design and results of any study, particularly qualitative, are enhanced when the epistemological underpinning and authors’ identity and positionality (e.g., social location and educational status, assumptions, and power/privilege) are clearly noted³⁷ (see Table 1); these reflexive strategies along with bracketing and field notes helped bring attention to the authors’ assumptions and biases that could influence analysis. As demonstrated by the introductory story, the PI’s experiences are intricately woven into the conceptualization and approach to nursing research with an older racial minority population. The research described herein uses critical constructivist and pragmatic perspectives to construct and present the realities of older Black women with chronic pain living in the south.

Table 1.

Epistemological Position and Intersectional Identities of Authors

Statements of Identity	Hold a Position of Influence (or Power)	Research Population of Interest
S.B.: Is not a feminist or womanist, but appreciates conceptual work that illuminates the racial and gendered experience of African American/Black older adults. Is not representative of the female participants in terms of select demographics, such as age, educational status, and socioeconomic status. Is an African American native of the geographic region from which participants were recruited and is highly spiritual in the same manner as the women described. Is a geriatric and pain management nurse. Is a member of Black sorority. Was raised by “Strong Black Women” and too identifies as a millennial Strong Black Woman.	Profession: Yes Community: Yes Academia: No	African American Older Adults Chronic Pain Racial disparities
L.C.: Identifies herself as a spiritually sound, Strong Black Woman who bears the weight of intergenerational trauma passed down by generations of Black women who faced daily racial and gender discrimination living in the Southern region of the U.S. Is not a feminist or a womanist but personally understands the importance of the conceptual framework that illustrates the lived experience of older Black women in the deep south. Identifies as a Xennial, born on the cusp of when Generation X and Millennials meet. Is not representative of the female participants regarding age, educational status, and socioeconomic status. Is an Adult-Gerontology Primary Care Nurse Practitioner and Nurse Scientist. Is a member of Black sorority.	Profession: Yes Community: Yes Academia: No	African Americans across the Adult Lifespan Cardiovascular Disease Cancer Multimorbidity Psychosocial Care Racial disparities
V.J.-M.: Is a member of Black sorority. Is a board-certified women’s health nurse practitioner. Relates to topics/schema of the paper. Has provided medical care to population of study.	Profession: Yes Community: Yes Academia: Yes	African American Women Women’s Health Management and treatment of chronic diseases specific to women Culturally appropriate behavior interventionist

RESULTS

Demographics

Our parent study sample was 82% (N= 90/110) female, while our qualitative sample was purposefully designed to be 50% female (N=9/18). These nine women were diverse in their age (50-85 years), education level, and reported either mild (N= 1), moderate (N= 4), or severe pain severity (N= 4). They also reported an average of nearly three chronic conditions aside from OA.

Unspoken Bonds- A Sisterhood in Pain: The Qualitative Perspective

As the study’s primary aims elucidated the experience of living with and managing OA pain, signs and sentiments of strength surfaced. Granted, strong overtones of strength may be influenced by the geographic setting of the study— “The Bible Belt.” We found evidence to support the five charcteristics of the SBW and two new emerging characteristics that may be specific to the generation of older Black women interviewed. In total, these seven characteristics were: (1) Obligation to present and personify an image of strength, (2) responsibility to suppress emotional expression, (3) resisting vulnerability or reliance on others, (4) motivation to succeed despite limited access to resources, (5) prioritizing others’ well-being over self-care, (6) spiritual submission to God for strength, and (7) code switching/shifting between Strong Black Woman to Suffering Black Woman.

Displays of strength were relative to a woman’s personal situation and daily fluctuations in pain and physical ability; more importantly, strength was not only a mental/spiritual concept but also a physical concept. For example, some women discussed improving the strength in the legs and upper body to deal with mobility changes due to chronic pain (e.g., “I be prayin’ for strength in my legs every day.”). Small portions of data noted by italics and bolding have been included in other publications and presentations.

Characteristic 1: Obligation to Present and Personify an Image of Strength.

Older Black women often presented the appearance of being strong and a family pillar as a method of self-preservation as mother, sister, caregiver, friend, and woman: “You got to be the strong person. Yep. No, it’s not easy” (W1). Women did not want to appear sick, “crippled,” or in pain and found ways to hide physical joint deformity and prevent the appearance of being disabled.

I’ve always been, I think, pretty strong. Even before this, that’s what people deemed me as. I was the oldest child. I always accepted a lot of responsibility which my parents were great parents. I’m just sayin’ in terms of where I am in the family, I’m the oldest. I’m a person that take care of other people all the time. I always had that nature from what I’m told.

(W2)

Most time they ask me, “You alright?” I say, “I’m doing fine,” but it [knee] be hurtin. I don’t like folk keep harassing me about, “You alright?”

(W3)

[Field note #1: Black people have been in survival mode since slavery and just suffer through pain.]

Characteristic 2: Responsibility to Suppress Emotional Expression.

The silence of emotional distress in women was not only audible but palpable as women invited us into their daily life of chronic pain. Women had to either suppress their emotions and/or carry a positive outlook and disposition regardless of pain. It was rare for women to admit when they were experiencing pain, and one woman offered that “Pain wouldn’t be anything new for us [Black people]” (W4; See Field note #1). With this behavior embedded in the cultural psyche, it was easy to minimize pain and the prognosis of OA.

A lot of us, when it comes to this arthritis, we don’t wanna own up to it. Just point blank like we don’t wanna admit that we got it. We don’t wanna admit that we gettin’ old, that we havin’ this joint pains. My friend, he don’t wanna admit that he’s gettin’ it, cuz if you can’t get up out the bed sometime in the mornin’ time, you gotta take two Bayer back and body, it take you 30 minutes to an hour before you can move… You gettin’ it.

(W1)

As previously documented, older Black adults desperately desire and need affective, physical, and emotional support from their loved ones.²⁰ There were a few women willing to express their emotions and experience.

I don’t mind telling people. ‘Cuz you know sometimes you can help others. They might be in pain. You could say, “Well, I have the same pain. It’s arthritis. Why don’t you check your doctor to see…” That’s what I try to encourage people to do. I’m not ashamed of anything that happens to me.

(W5)

There are times when, and I have to be honest, I don’t say anything to her [adult daughter]. Because I don’t want her to be alarmed about this or that, whatever. If I do share, I will share with her. Mm-hmm. … no man is an island. We need to share with someone. Your feelings. A friend of mine that I talk to, one other person that I do share with, good friend of mine that I share with. She say, “You got to share with somebody. Only that I don’t know, but if you’re hurting. Let [daughter name deleted] know.” I do do that, but I don’t always do that with everybody. Used to do that for many years. Sing all the time. Sometimes I do it for me, because that’s what I need, and at the same time, if it blesses someone, well and good. Most of the time, it’s for me, ‘cause I need release, ‘cause I’ve allowed myself to get to that point. You know what I mean?

(W6)

Characteristic 3: Resisting Vulnerability or Reliance on Others.

Resistance was mainly driven by the need to remain physically independent and to thwart others’ negative perceptions about having a debilitating condition and being labeled as weak or incapable.

You’re not ready for everybody to see that. You done got here. You still wanna be who you was. And you haven’t accept the fact that you’re not.

(W1)

They just worrisome. I’m always like, “Don’t ask me all them questions.” I say I’m alright, leave me alone, go on. That’s how I am. I don’t like to bother nobody when I’m feeling bad or sick or hurtin. I don’t. That just me.

(W3)

However, the nature of chronic pain and its impact on physical abilities at times required vulnerability or dependence on (and recommendations from) others. Thus, resistance to vulnerability did not always mean resisting or refusing help. In a previous publication, we demonstrated that help was welcomed as long it was not accompanied by pity.²⁰ Behavioral display of vulnerability included accepting help around the house, asking family and friends with OA for recommendations to control pain, and sharing their experience with trusted individuals, such as very close friends or church members and the PI. One woman in particular had been receiving care from a home health aide for nearly three years but recognized the resistance in others: “A lot of people just don’t ask for help. I don’t know what it is with people. … I know it bothers some people, but it doesn’t bother me” (W9).

[Field note #2: Help is good but don’t want pity.]

Characteristic 4: Motivation to Succeed Despite Limited Access to Resources.

When asked, “on a scale of 0-10 (0= no motivation, 10= high motivation), how motivated are you to manage pain?”, participants reported high motivation (Mean= 8.9; Range=7-10). Yet, motivation to action was hindered by financial and community resources, emotional support, educational opportunities, and limited options for treatment. Motivation to succeed in this sample of chronic pain sufferers manifested more as the strength to endure and refusing to let pain stop their life.

To me, I think a lot of it’s got to be self. If you want it. If you wanna manage that pain, it’s got to be up here. I can do this. I’m gonna manage this…. You gotta encourage. Plus, I feel like if you had other people in the same situation that help to give you that support, too. Like tryin’ to quit cigarettes. If you had a little support, well, okay. Well, we gonna work this together.

(W1)

Every doctor I talk to tell me, “You’re crazy for not takin’ pain medicine.” My rheumatologist was tryin’ to give me pain medicine. I told them no. I told them my reasoning. He said, “I admire you for that.” I said, “Well, it’s not to be admired. It’s just that for me, I’ve got to take care of [self], and nobody else is gonna do that.” Because medicines put me through more changes than anything in my life.

(W2)

Characteristic 5: Prioritizing Others’ Well-being over Self-Care.

Only two women were directly caring for grandchildren on a regular basis. While most were not formally caregiving, this did not preclude fulfilling role expectations as wives and mothers. For example, one woman whose husband also had OA took on the responsibility of purchasing their treatment relief products. Another woman living with her adult daughter discussed caretaking activities:

I find myself pushing myself a lot, and this is where my mom was. I’m a lot like her. Just always, I’m in the house, I got the wash, I got to do dishes, I got to cook. I got ten things goin’ at one time. “Momma’s—“ [laughter] since then that’s why you feel the way you are. Once I can sit down and relax, I’m good [laughter].

(W6)

One woman illuminated the transgenerational effect of a Black woman’s strength and sacrifice for her family:

My father helped with some things, but my mom basically was the one. I’ve had 15 major surgeries. Every surgery I’ve had she was there except for the last one that I had. When I was tellin’ you I was in the hospital, and she was there. No matter what. Would take a leave of absence from work. Would stay in the hospital. People would say, “That’s a grown woman.” My mother would say, “That’s my child.” She would be there no matter what. Baby, that’s what helped me got through. If your mother is there and you can’t walk, don’t you know you gonna get up and walk? Don’t you know I wasn’t gonna let that be? If I knew she was there and she was a strength, it gave me strength.

(W2)

Caregiving took on the form of providing emotional support for others and the obligation to suffer and be strong.

I mean, because I tell people, when I met people with RA, OA, and even gout and other arthritic conditions, they would tell me, “I don’t wanna complain to you because you’ve been through so much.” I tell them, “No. Stop. Because whatever is hurtin’ you, if you don’t have nothin’ but an arm hurtin’ you, or even if it’s a finger, that’s still… that’s pain to you, and that’s your severity.”

(W2)

Self-care became a priority after the development and progression of osteoarthritis, and the importance of self-care for themselves and other family members was heightened. Women reflected on missed opportunities at early ages to engage in healthy behaviors.

What we need to do is just encourage one another to actually take care of ourselves. … I do a number of different things. When I was diagnosed with osteoarthritis, I really had never heard of it until I was affected by it. A lotta times, we don’t start looking into. That’s why I was saying, if we could get into preventive measures. I started pulling—my daughter pulled the information offa the Internet. I did gather up—I talked with the doctor, but I gathered up information from the doctors’ offices, in the clinic that I went. I’d ask, “Do you have some additional information about osteoarthritis?” I’ve even had, some of the nurses, would even pull up some things for me. I took the initiative to get that.

(W6)

Two additional characteristics emerged from the data: Spiritual Submission to God for Strength and Code Switching/Shifting between Strong Black Woman to Suffering Black Woman. These add to the SWB and perhaps are more specific to the experience of chronic pain.

Characteristic 6: Spiritual Submission to God for Strength.

One aspect of being a strong Black woman living with chronic pain was their reliance on God for strength. In contrast to Woods-Giscombé’s theme of resistance on dependence on others for support,¹⁸ participants were very vocal about their dependence and need for God and Jesus Christ. God was the primary source of strength, and women believed that “He gonna give you the strength that you need”.¹ Frequently, prayers centered on supplication for strength to bear, ease, or remove the pain.³⁶

Maybe they [friends or family] can send up a prayer to help me. [Laughter] Yeah, I sure will. I ain’t that strong to try to figure it out on my own. Hm-mmm. I want somebody to know I’m in pain.

(W7)

Baby, that’s what helped me got through. If your mother is there and you can’t walk, don’t you know you gonna get up and walk? Don’t you know I wasn’t gonna let that be? If I knew she was there and she was a strength, it gave me strength. Because it’s a lot of procedures. Just stop it [recording paused due to participant becoming emotional]. I think when you’re young you don’t really fear very much. I think that helped a lot too. That was my strength. Knowing God and she was a Christian woman as well. She put those values in me. Cuz see we loved the Lord.

(W2)

[Field note #3: God gives the strength you need.]

This was not a vicarious strength, but a renewed strength to fight on another day; “Every day, it’s a fight. I’m not gonna tell anybody it’s easy, cuz it’s not. It’s a fight to be up and be going” (W8). Faith was the central concept in their image and modeling of strength, where all women mentioned the importance of recognizing the silver lining and daily blessings. “That thought come to my mind, but you know when you live to see 81, you get in your 80’s, and God blessed, done give you some blessing already” (W7). One woman summarized it nicely:

Through God I know all things are possible. That’s what I believe, baby. I wouldn’t be walkin’. They don’t understand to this day how blessed I am… So I’m trusting God. I think if they had not been for him, darlin’, I would be dead. I know I would. …No matter what you go through, we’re to persevere, as Paul said. Paul was sick, and he walked with Jesus. Paul was, of course, one of his beloved disciples, one of his favorites. Those people really persevered. See we take life for granted. We think we’re here for our own purpose. We’re here to draw people to Christ. No matter what you go through, that’s what you got to be is a livin’ example.

(W2)

Characteristic 7: Code Switching/Shifting between Strong Black Woman to Suffering Black Woman.

Code switching or shifting involved changing behavior (e.g., stoic, friendly, or crying), communication patterns (e.g., using proper “English”), and physical appearance (e.g., hair, clothes) to summon the appropriate attention to their acute pain needs while simultaneously reducing (1) providers’ preconceived misconceptions, (2) being labeled as aggressive, unkempt, or low-income and low-literate, and (3) being viewed as complainers and/or liars. The ultimate intention for code switching/shifting was to obtain timely, appropriate, and quality care from providers. At times, upholding the image of a Strong Black Woman or suppressing emotions do not fare well for older Black women when seeking healthcare services. Research has consistently shown that African Americans/Blacks in pain are not always believed and assumed to be drug- or attention-seeking, neither of which have reliable supporting evidence. Thus, our participants had to demonstrate their vulnerability and physical pain through outward behaviors, such as crying. It was not easy for women to show “weakness”, but this was an intentional and real behavior in order to receive basic healthcare and pain management. For example, rather than assume the Angry Black Woman Stereotype,³⁸ one participant unashamedly displayed her emotions when she visited a local primary care clinic:

I literally had to go in there the same way. In tears. All that he did was took x-rays and, okay. Here. Take these pain pills and go home. That’s it. That’s all they do…. Even if it’s in the emergency rooms, they look at you the same way, cuz when I was sick with that pain up under my arm, I just told ‘em just like this. I went twice. I went three times! Back and forth to the emergency room when I had this under my arm. I was literally—my legs had red spots all over. Oh take some ibuprofen and go home. They actually think only Black—well, we messed ourselves up. The only thing they think is that we come in here for pain medicine.

(W1)

She went on to explain that this kind of dismissive care keeps Black Americans from going to the doctor. On the other hand, some older women preferred not to visit the doctor despite suffering because they knew they would not be provided holistic care. As Jeffries states, “labeling Black women as an SBW reduces the quality of health care, while forcing Black women to advocate for better care”.^13(p4) This was demonstrated in our study when some women displayed changes in behavior as a means to advocate for themselves and to challenge the traditional paternalistic patient-provider relationship. Consequently, this was viewed by providers as being assertive and challenging the providers’ expertise.

Most primary care doctors, they only have, what, maybe ten minutes. If you’re a person who they describe as a complainer, then it’s gonna be like five. You better get to it and hurry. Or, here’s another thing that I found out. They don’t want you to have no knowledge of what’s wrong with you. Now, isn’t that sad? That is sad. Cuz I had even my own primary care doctor, I had read a book cuz some things was happening about my stomach. She said now we working on dealing with you, out of your book. I said wait a minute. I said here’s what the book says, that it says, and if I have this, then maybe I’m having that. I said what I want you to do is find out what it is. Start at step one. It says we do a x-ray. She wasn’t happy with that, but she did do it. It helped me because we found out what my problem was. It gave three things that possibly could be the reason for that pain. When they did the x-ray, that’s when they found out that it was the gallbladder, and I had gallbladder surgery. See, so had I not been forceful, because we’d been talking about that for a while.

(W8)

In addition to code switching with providers, participants often spoke in code with family and friends. We previously noted cognitive-verbal-behavioral discordance in Black women wherein they didn’t believe in or explicitly talk about pain with other close women in their life and would use subtle code statements, such as “I don’t feel well today”.¹ Expanding on this coded talk were demonstrations of pain-related behaviors (body language) that others would need to recognize and decipher to identify and interpret the presence of pain.

But I have a very close friend. She can look at me and tell when I’m in pain. Most people say they cannot tell. Because she knows my mannerisms so well she knows different things I do like when I’m in pain. I take my hands and do a certain thing. I do certain other issues that she’s just been around me so much she knows me.

(W2)

Unspoken Bonds- A Sisterhood in Pain: An Integrated Perspective

This analysis uncovered that the strength has layered dimensions. Chronic pain was a significant problem among Black women, and being a SBW alone may not be enough to effectively control pain severity. Strength was displayed more often as a state rather than a trait, meaning that strength was situational and influenced by their social environment. Embracing or rejecting the SBW was dependent upon (1) the manner in which an Black woman conceptualizes or views the sociopolitical-cultural environment and (2) their assessment of the perceived benefits or harms on well-being. For example, some Black women may not embrace SBW, at least in public and healthcare settings, on the premises of disassociating this characterization from the angry Black woman stereotype.

DISCUSSION

Women represent a large proportion of persons living with chronic pain; yet their pain has been neglected and dismissed, making it more difficult for racial minority women to receive state-of-the-art pain care. Kate Nicholson, a civil rights attorney and founder of the National Pain Advocacy Center eloquently articulates the experience and expression of strength and pain:

Pain is a dance. And as any dancer knows, it’s about finding a balance between strength and flexibility or strength and fragility; between surrender and fight; between learning self-care, but also letting other people take care of you; between meeting your goals and going out toward them, but also resting when you need to; between experiencing difficult emotions, truly grieving them, but then letting them go and not holding on to them.^39(p30)

Our results add a new perspective to the current literature and support a recent report that places chronic pain in women as a new priority for the nation.³⁹ Using the SBW frameworks, we found evidence to support the five tenets, with some slight variations in the representation of each tenet. The ideal standard of a SBW is instilled from childhood- homage to our past female slave ancestors/descendants and a model image to our current young Black woman. The transgenerational strength and resilience of Black women are highly celebrated and, at the same time, are a source of normalized burden in which Black women are expected to be strong at all times. The Black woman has been branded by society and by themselves within this parallel of being strong and gritty and thus are psychologically and emotionally invulnerable to hardships.⁴⁰ The racial typecast about the Black body as strong and impenetrable⁴¹ feeds into healthcare biases wherein providers may have an unrealistic perception on how Black women sense pain, then dismiss the legitimacy of the complaint or severity, and ultimately feel less inclined to treat pain. In response to the historical mistreatment of pain in Black individuals, Black women have learned to care for themselves, utilizing the limited physical, medical, and emotional tools at hand.

“Being strong” has served as a traditional coping mechanism permitting Black women to successfully handle adversities while being a leader in her family and community without complaint and much assistance.⁴² Thus, assuming the SBW role or superwoman persona can undoubtedly lead to emotional pain when internalization of this role is surrounded by negative situations and constant social and familial challenges. In return, the stress associated with strength can exacerbate existing chronic pain. The SBW acknowledges that Black women must be all things to all people; in fiction, that character trait describes superwoman and wonder woman. Taking on this role and mentality may adversely affect their health and increase anxiety, stress, depression, and even spiritual fatigue. Black women epitomize the best and worst characteristics of Black strength, which could impose instances of social injustice and apply a burdensome stereotype on the women living with chronic pain. Some may label this as “toxic femininity,” but this characterization transforms an endearing cultural trait into a purely negative one. Instead, this paper posits that a Black woman’s strength be viewed in its proper context.

Two important thoughts to higlight: (1) drawing on personal strength is more likely to be rapidly depleted, necessitating vicarious strength from God or other spiritual avenues and (2) strength is learned and promoted in several spiritual sources, such as hymnals/Negro spirituals, women in the Bible, and Biblical scriptures. Many Black American women maintain a Christian worldview, as was demonstrated by our qualitative informants. It is important that SBW do not lean on and draw only upon their personal strength but seek renewed strength from God, for “God is our refuge and strength” (Psalm 46:1a). 2 Corinthians 12:9 states, “And he said unto me, My grace is sufficient for thee: for my strength is made perfect in weakness. Most gladly, therefore, will I rather glory in my infirmities, that the power of Christ may rest upon me” (King James Version). Participants readily declared being blessed despite having OA and physical limitations. Buck and Meghani defined this as the ‘living paradox’ in that African Americans with cancer pain could simultaneously experience blessings even amid pain.⁴³ In the scheme of things for Black Americans, the pain was a small price to pay if their experience could help someone else or show gratitude and appreciation for Jesus’ sacrifice. Feeling blessed and relying on God to heal and alleviate arthritis pain was also noted by another study.⁴⁴ An attitude of gratitude permits older Black Americans suffering from debilitating OA to create meaningful life roles, cope with the emotional consequences of pain, and manage the variability in pain.

Pain is not a visible symptom, and a magazine article on chronic pain that the PI recently read stated, “Invisible pain is not absent pain”. Often times, the invisibility of pain prompts others to believe that pain is not present. The “invisible Black woman” perfectly characterizes how Black women are ignored and unfairly treated in healthcare when seeking pain relief.⁴⁵ Because Black women are ‘invisible’, so is their pain. This is further complicated when Black women hide or cover up their pain¹ and continue to “assume position” as if in an army of female warriors or pain warriors. When these stereotypes or traits are applied, it can result in an unspoken false dichotomy: Warrior vs Worrier where Black women are portrayed to be so strong that they can endure even the worse of physical pain contrary to what they report. The warrior suffers through the pain while the worrier may employ behaviors consistent with pain catastrophizing. When misunderstood by healthcare providers and nurses, their expressions of pain could be categorized and stigmatized as pain catastrophizing. As such Black women become silent sufferers for a cause that could ultimately kill them. Indeed, mortality has been associated with chronic pain,⁴⁶ suggesting that “pain never killed anyone” is a misnomer. This signals an urgent need to manage chronic pain as aggressively as other chronic diseases and to shift current views about pain disparities to foster change and equity.⁴⁷

Future theoretical and applied psychosocial-behavioral research is merited in older adults to establish a conceptual model for understanding pain-related strength, its protective and perilous factors, and how its manifestation may differ across racial groups, age cohorts, and gender identities. Specifically, future studies should examine how Afro-centric strength and chronic pain may vary or align across ethnic groups within the Black American diaspora, including descendants of African slaves, Afro-Latinx, Afro-Caribbeans, and African immigrants/migrants. Lastly, examining the intra-racial experiences of Black women allow researchers to draw more ecologically valid and socio-culturally valuable conclusions when making comparisons to different racial subgroups.

There is a pronounced need to design family-focused pain interventions and education that go beyond traditional methods of pain assessment and management and integrate the cultural needs and values of Black patients.^20,48 This is an opportunity for more personalized pain interventions and self-care that utilize the “sisterhood”. There are several well-known Black women support groups or “sister circles” for various health conditions,⁴⁹ such as breast cancer (e.g., Sister’s Network), mental health (e.g., Sistah to Sistah), heart disease, spondyloarthritis (e.g., Black Ladies with AS Standing Tall (BLASST)) to name a few. However, there are none for general chronic pain or OA, and leveraging some of the current support groups by threading chronic pain as a topic could strengthen health management behaviors among Black women. Further, resources such as AARP’s Sisters Letter is an avenue for evidence-based education on chronic disease management. In all, clinicians can help Black women achieve balance and become attuned to their biological and psychosocial needs by addressing pain holistically, such as spiritual interventions through pastoral care, faith-based nursing, family-focused pain management, and values-based psychological counseling.

The strengths and limitations of this exploratory study emanate from conducting research in the real-world setting. Our data are limited in that our original purpose and subsequently interview guide did not ask participants to discuss or describe experiences or meaning of strength in a chronic pain condition. It is possible that we did not reach code or theoretical saturation for themes 3 and 4. However, our community-derived sample serves both as a strength and limitation. We engaged in intensive community outreach, education, and recruitment to accrue a robust sample. The systematic selection of a purposive sample allowed for descriptions of a range of experiences, and stratification of participants by pain severity permitted us to make cross-case comparisons. While our community-based sample was diverse in select characteristics, the regional homogeneity of culture precludes making sweeping claims about any specific sub-groups of African Americans/Black older women. Still, support from the literature suggests the cultural transferability of our findings holds. Our sample size was limited to nine women by methodological design, which comprised only 50% of our total qualitative sample size. Because the authors are Black nurses and self-proclaimed SBW, systematic steps were taken to make certain that personal biases and ideals did not skew the interpretation of results.

CONCLUSION

The strength and resilience of older Black women with chronic pain is an important topic. As Black researchers studying Black adults, we continue to ponder how we as Black women survive and manage health and pain in the midst of our own gender adversities along with dealing with racial violence against our Black men—our husbands, sons, brother/brothas/bruhs, nephews, cousins, and friends. Reflecting on the lead-in true story, it is unknown how Ms. Janice’s story would have changed if the PI had revealed her career as a nurse scientist investigating pain in aging Black Americans. Perhaps other elements of strength and perseverance may have emerged. Still, Ms. Janice glowed with a profound strength stronger than any diamond. In conclusion, it is only fitting that we leave you with an excerpt from a speech that has resounded for over 165 years by Sojourner Truth who epitomized the simultaneous strength, pain, and injustice suffered as a Black woman:

I could work as much and eat as much as a man - when I could get it - and bear the lash as well! And ain't I a woman? I have borne thirteen children, and seen most all sold off to slavery, and when I cried out with my mother's grief, none but Jesus heard me! And ain't I a woman?

(excerpt from “Ain’t I A Woman?”, Sojourner Truth, 1851, Akron Ohio)⁵⁰