Method: The study uses focus groups and in-depth interviews to explore the experiences of 30 black middle-class women between 35 and 65 years old. Respondents were selected to reflect variation in: a) education; b) income; c) occupation; and d) home ownership. Although much of the research on race and health status focuses on the interaction of race and poverty, participants ranged from lower middle to upper middle class. Results: Respondents overwhelmingly endorsed the importance of positive self-presentation to mitigate differential treatment. They noted that in order to minimize the likelihood of differential treatment, they must demonstrate specific knowledge of their own health status and of specific health conditions, which was burdensome and distracting. In keeping with the literature on race concordance, respondents did not necessarily prefer a black provider. Rather, a trusting relationship with a competent provider was more important. They reported that they did not interpret their experiences in health care settings to be overtly discriminatory. However, all respondents agreed that discrimination against blacks continues to be pervasive, in health care settings and in general. They also experienced a “double burden” of being black and female. In addition, differences between lower middle and upper middle class women emerged in the specific self-presentation strategies they employed. Women in the upper middle class group emphasized the importance of sophisticated verbal communication, articulation, and avoiding black vernacular. Women in the lower middle class group often felt providers were dismissive of their concerns and there was nothing they could do to mitigate the treatment they received.
Conclusion: The study provides important information about an understudied group. Although black middle-class women have resources, they are not immune to bias. They have their own strategies for mitigating bias by emphasizing certain resources, i.e., specific knowledge of health care issues, demonstrating intelligence, etc. Although the women did not uniformly report overt instances of discrimination, they felt black women were subtly discriminated against in ways that often go unnoticed. The study highlights diversity within the black middle class as it is generally defined in the literature. Upper middle class black women reported feeling empowered by their education and highly developed verbal communication style. These findings highlight the dynamic interplay between patient and provider. They also suggest that interventions designed to reduce social distance within the patient-provider dyad may be effective. Finally, because black middle-class women have many social identities, interventions based solely on increasing race-concordance are unlikely to completely reduce health disparities.
