595847

research-article2015
HEA0010.1177/1363459315595847HealthAndrews et al.

Article

Health

Strong, female and Black: 1­–16

© The Author(s) 2015

Stereotypes of African
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DOI: 10.1177/1363459315595847
Caribbean women’s body hea.sagepub.com

shape and their effects on

clinical encounters

Nicole Andrews and Sheila Greenfield

University of Birmingham, UK

Will Drever
Hawkesley Medical Practice, UK

Sabi Redwood
University of Bristol, UK

Abstract
The aim of this article is to explore how tendencies to stereotype minority ethnic
groups intersect with lay discourses about them in ways that can reproduce cultural
prejudices and reinforce inequalities in access to services and health outcomes. Drawing
upon Black feminist and cultural studies literature, we present a theoretical examination,
the stereotypes of the Black woman as ‘mammy’ and ‘matriarch’. We suggest that the
influence of these two images is central to understanding the normalisation of the larger
Black female body within African Caribbean communities. This representation of excess
weight contradicts mainstream negative discourses of large bodies that view it as a form
of moral weakness. Seeking to stimulate reflection on how unacknowledged stereotypes
may shape clinical encounters, we propose that for Black women, it is the perception of
strength, tied into these racial images of ‘mammy’ and ‘matriarch’ which may influence
when or how health services or advice are both sought by them and offered to them.
This has particular significance in relation to how body weight and weight management
are/are not talked about in primary care-based interactions and what support Black

Corresponding author:
Sabi Redwood, School of Social and Community Medicine, NIHRC CLAHRC West, University of Bristol,
Whitefriars, Lewins Mead, Bristol BS1 2NT, UK.
Email: sabi.redwood@bristol.ac.uk

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2 Health 

women are/are not offered. We argue that unintentional bias can have tangible impacts
and health outcomes for Black women and possibly other minority ethnic groups.

Keywords
Ethnicity, health inequalities, overweight and obesity, patient–healthcare professional
interaction, stereotypes

Introduction
In this theoretical article in which we draw on upon Black feminist and cultural studies
literature, we explore how tendencies to stereotype minority ethnic groups intersect with
lay discourses about them in ways that can reproduce cultural prejudices and reinforce
inequalities in healthcare access and health outcomes (Laird et al., 2007). We focus on
stereotypical images of African Caribbean women in relation to body shape and body
size, and highlight how unacknowledged bias in clinical interactions may limit the value
of discussions about health, especially about weight and weight management support,
and prevention of obesity-related chronic illness such as Type 2 diabetes and cardiovas-
cular disease. Empirical approaches to measuring the body such as the body mass index
(BMI) are used to categorise an individual as underweight, healthy, overweight, or obese
(Reddy, 2006). The epidemiological literature indicates that there are high rates of over-
weight and obesity in African Caribbean groups compared to the general population in
the United Kingdom and that excess weight in African Caribbean women is higher than
in the general population; 65 per cent of African Caribbean women are classified as hav-
ing an ‘unhealthy’ high weight compared to 57 per cent of White British women (Hirani
and Stamatakis, 2006).
Exploring the intersection of race, ethnicity and gender in relation to the discourses
about the ‘fat body’ and Black femininity, we consider how these discourses might oper-
ate in clinical encounters and interactions about overweight and obesity between health-
care professionals and women from African Caribbean communities. While the influence
of stereotypes of Black women has been explored within the context of mental health
(e.g. Edge and Rogers, 2005) less attention has been paid to how such stereotypes may
influence perceptions of weight and weight management. The aim of this article is to
stimulate reflection on how unacknowledged stereotypes may shape clinical encounters
at a time when health seems to have become visually accessible by ‘being manifest in the
parameters of the body’ (Grønning et al., 2013: 267).
Starting with a brief historical investigation of the image of the Black female body,
we address how the larger Black body is ‘normalised’ within African Caribbean, and,
indeed, mainstream society. We discuss how this particular view of the body is tightly
bound up with the stereotypical imagery of Black women which portrays them as
strong. This association of larger body size and strength for Black women exists in
tension with mainstream views, which link excess weight with poor levels of health
and fitness, and with weakness, especially moral weakness. We suggest that this
notion of strength influences the health behaviours of African Caribbean women.

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Andrews et al. 3

Consequently, healthcare professionals’ prescription to lose weight may be inter-

preted not as an invitation to increase levels of well-being and fitness, but as a demand
to relinquish their strength.
The theoretical perspectives explored in this article are rooted in social construction-
ism, and this analysis is part of a wider empirical research investigation that seeks to
examine African Caribbean women’s discursive and cultural constructions of health with
particular focus on body shape and size. The aim of the empirical work is to examine
how biomedical knowledge is assimilated, reconstructed and transformed by a number
of different discourses including cultural stereotypes, and popular medical science and
lifestyle advice disseminated by various media. Researchers working with a social con-
structionist framework challenge the humanistic understanding of the individual as sta-
ble, rational, independent and autonomous. Rather, they see subjectivity as constructed
through social processes which include the various discourses, historic and cultural as
well as popular scientific, that are operating in a society and thus available to individuals.
While we share the critical outlook of the social constructionist project by contesting
what might be called the ‘conventional wisdom’, we do not subscribe to the more radical,
nihilistic constructionist idea that it is impossible to produce legitimate knowledge (for a
discussion of these issues, see, for example, Bury, 1986). Such a position condemns
everything and proposes nothing to advance practice (Bauman, 1992). Instead, we draw
on Black feminist and cultural studies literature to examine the wider cultural meanings
around bodies and how they intersect with social constructions of gender which we posit
can be fruitful in highlighting what unacknowledged discourses may be operating during
clinical encounters about excess weight.
Recognising that defining and labelling ethnic groups in health research is both com-
plex and problematic, we follow the principles described by Bhopal (2004). The modern
utilisation of the concept of race refers to its social source rather than biology and pro-
vides a way of defining, for social purposes, populations that look different and have
different ancestral roots (Bhopal, 2004: 442). The term ‘Black’ refers to people of African
ancestry; ‘White’ refers to people of European descent. The use of the term ‘Black’ is
important for this discussion as it draws on the discourses and experiences of people of
African descent in Europe and America (Walvin, 2000). We will refer to the body of
African American research conducted with Black women which we will draw into the
British context. In this article, the term ‘ethnicity’ refers to ‘the group to which people
belong, and/or are perceived to belong, as a result of certain shared characteristics,
including geographical and ancestral origins, but particularly cultural traditions and lan-
guages’ (Bhopal, 2004: 441). Ethnicity will be denoted by terms such as African
American, African Caribbean, and White British.

Understandings of the body

Against a background in many parts of the world of easy access to high calorie/high fat
foods and a reduced need to engage in physical activity, excess weight and large body
size have become problematic for health. Biomedical evidence suggesting that these
present a major threat to health has resulted in discourses about a global ‘obesity pan-
demic’ which no public health system in the world has been able to reverse (Swinburn

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4 Health 

et al., 2011). In an attempt to address the nation’s weight problems, the UK National
Health Service (NHS) has called on healthcare professionals to ‘make every contact
count’ by encouraging conversations with patients about health and lifestyle based on
behaviour change methodologies (NHS Future Forum, 2012). Such techniques and prac-
tices reflect what Foucault (1973) termed the ‘medical gaze’, an orientation on which he
saw modern healthcare practice to be predicated, targeting the body as an object to be
presented for scrutiny, classification and treatment. This medical gaze is especially pow-
erful because it shapes and maintains the production of knowledge about the body within
biomedical and mainstream societal discourse while marginalising other forms of under-
standing (Foucault, 1973, 1980). To identify patients with an ‘unhealthy’ weight, health-
care professionals use objective measures, such as the BMI scale. Indeed, it is argued that
the adoption of standardised means of assessing overweight in both populations and
individuals has facilitated the development of an ‘obesity science’ and the reasoning that
has led to the claim that current population trends point to an ‘obesity epidemic’ (Fletcher,
2014). However, the validity of the BMI as a universal measure has been questioned and
other measures such as waist circumference and hip-to-waist ratio may provide more
accurate indication of risk to health (Dobbelsteyn et al., 2001).
While the biomedical evidence is unequivocal, pointing to an imbalance between
energy intake and energy output, it is far from clear what approach should be taken to
assist people to achieve a balanced weight. There is much professional guidance about
how issues of weight management may be raised, yet in practice it is often a matter of the
relationship between the healthcare professional and the patient which is ‘one of the most
complex […] and is therefore emotionally laden and requires close co-operation’ (Ong
et al., 1995: 903). Research suggests that general practitioners and practice nurses are
apprehensive about initiating and discussing weight management with patients (Michie,
2007), citing concerns about offending or upsetting patients because of negative societal
discourses about fat which constructs the overweight or obese body as deviant (Mold and
Forbes, 2011) and the individual as weak and morally flawed. For professionals, these
stereotypes, alongside cognitive and emotional consequences for the individual, mediate
how and when the topic of overweight is broached with patients for whom the conversa-
tion is thought to be appropriate. However, while the powerful influence of the biomedi-
cal view of health and weight is evident in mainstream discourse, it is important to
recognise that alternative conceptualisations of excess weight and obesity exist and
shape ways that patients perceive their own health. In fact, Foucault suggests that alter-
native views that question the authority of the biomedical view are inevitable as the
power to define knowledge about the body and health enables the ‘possibility of resist-
ance’ (Foucault, [1984] 1997: 292) where discursive positions can be challenged or
resisted.
The contestation of power/knowledge manifests as a ‘reverse discourse’ (Foucault,
[1978] 1981: 101), offering alternative interpretations to expert definitions of health.
With regard to understanding body shape and size, alternative perspectives on what
constitutes a healthy body are made possible through an ‘oppositional gaze’ (Hooks,
1992), resisting the authority of the medical gaze to define health and normality, ena-
bling other meanings to be ascribed to the body and other stories to be told about health.
Similarly, healthcare professionals consulting with individuals and families from

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Andrews et al. 5

diverse communities need an understanding of a range of ‘oppositional gazes’ on mean-

ings of health, well-being and fitness that do not easily align with biomedical discourses
and that resist the idea of the risk of ill-health residing silently in their body. For exam-
ple, a UK study that explored attitudes to weight of both Black and White women,
Shoneye et al. (2011) found that Black participants had a more favourable opinion of
larger body sizes compared to their White counterparts. This finding echoes results of
research conducted in African American communities that reports a cultural normalis-
ing and acceptance of excess weight and obesity for women (e.g. Gilliard et al., 2007;
Schuler et al., 2008). In the following section, we explore the possible genesis of the
oppositional gaze on the Black female body.

The making of an image: the mammy and the matriarch

Drawing upon Black feminist and cultural studies literature, we examine the stereotypes
of the Black woman as ‘mammy’ and ‘matriarch’. We suggest that the influence of these
two socially constructed images is central to understanding the normalisation of the
larger Black female body within African Caribbean communities. Furthermore, such ste-
reotypes construct the large body as strong, which is an empowering oppositional gaze
to the medical gaze and mainstream views of the body.
There is a well-documented history of how Black femininity has been portrayed in
the West. One of the earliest stereotypes of the Black woman is that of the Black
‘mammy’. It is suggested that this classical, and most famous, representation of Black
women image emerged in the Southern states of the United States during the civil war,
a time when enslavement of Black people was extensive in the United States and
Caribbean (Collins, 2000). As the mammy, the Black woman is depicted as ‘fat and
dark, with “nappy” hair and a booming voice. She is ever-nurturing, though virtually
sexless’ (Williamson, 1998: 66). Through this image of Black women, a contrast
between Black and White femininity is set up. While White female beauty is defined in
terms of slenderness and fragility, producing a body unfit for physical work, the Black
female body is depicted as large and strong, yet not in terms of male strength and domi-
nance, but as indicative of its potential for low-status physical work and subservience.
Within plantation society, the role of the Black mammy was the enslaved woman who
‘became the maid of all work, caring for the children, washing, ironing, cooking, clean-
ing and helping in the fields as well’ (Parkhurst, 1938: 351). Portrayal of Black women
as mammies in the popular culture of the first half of the 20th century includes Hattie
McDaniel’s character ‘Mammy’ in the film Gone with the Wind; the recurring house-
keeper character ‘Mammy Two Shoes’ in the MGM Tom and Jerry cartoons; and Aunt
Jemima, the trademark logo image featured on Quaker Oats Company food products.
The emergence of the 1960s Black power movement in the United States critiqued such
depictions of Black women as undesirable and made popular the slogan ‘Black is beau-
tiful’ (Mercer, 1994: 98). This challenge to the notion of beauty prompted Black women
to celebrate their natural attributes – including a larger body size and shape, and non-
European hair texture and facial features – as a challenge to racism.
It is suggested that the mammy has not been relegated to history; rather this image of
Black women continues to exist in the form of ‘modern mammies’ (Collins, 2004: 138).

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6 Health 

Ascribing this label to Oprah Winfrey is not to diminish her success as a media personal-
ity and entrepreneur, but to critically engage with her image as a cultural icon for the
neoliberal era (Peck, 2008). In moving away from a particularly negative view of the
Black aesthetic, the modern mammy image of Oprah is one of a strong, hardworking,
nurturing confidante who is always receptive to the needs of those she serves, her guests
and her audience (Stanley, 2007). In an online magazine article, Oprah describes how
after years of struggling with her own weight, she has found her strength:

I did a head-to-toe assessment, and though there was plenty of room for improvement, I no
longer hated any part of myself, including the cellulite. I thought, this is the body you’ve been
given – love what you’ve got […] In that moment, as I stood before the mirror, I had my own
spiritual transformation […] What I know for sure is that the struggle is over. I’ve finally made
peace with my body. (Winfrey, 2002)

The mammy stereotype in its historical and contemporary forms suggests the notion
of strength which is linked to a large Black female body. Body size comes to represent
the strength to undertake physical manual tasks, to persevere through hardship, to care
for the family, to challenge negative representations of Blackness and to be comfortable
in one’s own skin. Thereby, in the process of accepting or resisting particular stereotypes,
the large Black female body is central to this symbolism of Black women and strength
(Beauboeuf-Lafontant, 2003). This conceptualisation is in stark contrast to mainstream
societal discourse, where individuals who are overweight or obese are conceptualised as
lazy, morally weak and out of control (Meleo-Erwin, 2011). Thus, despite images of
White female beauty of slenderness and vulnerability, ‘the most respected physical shape
of Black women, within and outside the community, is that of the large woman’ (Gilkes,
2001: 183). As if to underline this view, members of Oprah’s audience called into ques-
tion her legitimacy for giving advice and openly criticised her after she had lost a consid-
erable amount of weight (Stanley, 2007).
The second image of the Black woman is that of the matriarch, which also draws on
the notion of strength in relation to Black femininity. This image emerged in post slavery
US society and depicts Black women as aggressive, emasculating and fiercely autono-
mous within the family and wider society (Collins, 2000). This image is particularly
politically charged as it was used in labelling Black families as ‘pathological’, with a
focus on single mothers who often headed these families. It was in the United States dur-
ing the 1960s that this particular view of the Black matriarch was used to challenge to the
negative view of the Black family, in a similar way to the redefinition of beauty dis-
cussed earlier. The matriarchal image came to represent Black women’s rejection of the
placid mammy stereotype. However, the objection to the mammy is based on the image
of smiling servitude rather than on physical traits. The maternal features of the mammy
are retained, but transformed into a ‘more acceptable image of [Black] women as
“strong”’(Hill, 2009: 738). This construction of strength continues to permeate popular
culture where Black women are portrayed as tough, savvy and streetwise (Emerson,
2002). The flipside of this image of the strong Black woman is that she is also seen to be
hostile and aggressive. Michelle Obama, for example, responded passionately to claims
that she is matriarchal and said that she is tired of the ‘angry Black woman’ stereotype

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Andrews et al. 7

that influences the lives of many Black women (CBS News, 2011). While this construc-
tion of the matriarch is not underpinned by a particular body shape or size, it may influ-
ence how Black women address health issues. Women who internalise this image of
Black femininity as being strong and independent are encouraged to adopt the assump-
tion that they can ‘go it alone, without others, a notion that fosters silence and social
isolation among those who feel they are less than a woman if they show signs of weak-
ness and vulnerability’ (Taylor, 1999: 40).
Research suggests that there might be a relationship between the stereotypes of Black
femininity as strong and the health behaviours African Caribbean women engage in. For
instance, while there is an over-diagnosis of psychoses in African Caribbean communi-
ties, there is an under-diagnosis of neurotic disorders such as anxiety and depression
(Edge and Rogers, 2005) which may be seen as signs of powerlessness and vulnerability.
Similarly, findings from population-based studies indicate that there are significantly
higher rates of undiagnosed depression in this community compared to the White British
population, especially for women (Berthoud and Nazroo, 1997; Nazroo, 1997; Shaw
et al., 1999). Moreover, research into the low rates of self-reported depression and help-
seeking behaviour in women from this ethnic group suggests the possibility that the
image of the Black woman as the matriarch and historical connections to the mammy
role continue to shape understandings and lived experiences of Black femininity. In their
study into perinatal depression in African Caribbean women, Edge et al. (2004: 434)
quote a participant who states,

I think it all relates to slavery […] We had to be strong for our kids […] we had to protect them,
had to be strong for them […] and it’s just been instilled into the daughters […] that you need
to be strong, to hold your family together. You can’t depend on no man […] You need to be a
strong [woman].

This quote alludes to the shared narratives of African American communities in the
US and African Caribbean communities in the United Kingdom as both emerge from
post slavery Black Atlantic communities and how these may influence behaviours, health
and well-being. This social construction of Black femininity will be explored further in
the following sections in relation to perceptions of health, excess weight, and weight
management.

Alternative discourses
In this section, we will explore how alternative views of health that have currency in
African Caribbean communities might influence how epidemiological risks associated
with factors such as excess weight and obesity are conceptualised. Using the ‘preven-
tion paradox’ theory (Rose, 1985), the relationship between stereotypical views of the
larger Black body and perception of susceptibility for obesity-related chronic diseases
will be explored, using findings of research conducted with African Caribbean women.
We will go on to discuss the implications of this paradox for healthcare professionals
when talking about the associated risks of excess weight with African Caribbean women
in clinical settings.

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8 Health 

In a study that investigated the health beliefs of African Caribbean people, Brown
et al. (2007) report that the participants were well aware of the link between excess
weight and the onset of Type 2 diabetes. In fact, Shoneye et al. (2011) found that the
Black female participants were more likely to identify health as a motivator for weight
management than White female participants. However, biomedicine is only one of the
lenses through which risks to well-being may be perceived. Individuals and communities
construct their own knowledge about who is at risk of ill-health. The concept of ‘lay
epidemiology’ suggests that individuals comprehend and interpret health risks through
the everyday observation of health and illness in personal networks and public dis-
courses, through formal and informal information channels (Frankel et al., 1991).
Davison et al. (1991) propose that individuals are often aware of health risks as a result
of health promotion initiatives, and have an understanding of what defines an individual
as a ‘candidate’ for illness from biomedical perspectives. However, on a personal expe-
riential level, health, life and death defy epidemiological risk factors: ‘undesirable events
happen to some people sometimes, but not everybody always’ (Davison et al., 1991: 2).
This contradiction, termed the prevention paradox, refers to the observed reality that not
everyone who engages in risky health behaviour will go on to develop chronic illness,
and that some people who live apparently healthy lives will become ill. As health promo-
tion increases awareness in society, it simultaneously encourages attention to be drawn
to ‘unwarranted survivals and anomalous deaths that run contrary to public health mes-
sages’ (Allmark and Tod, 2006: 461).
For insight into the normalisation of excess weight and obesity in African Caribbean
communities, the prevention paradox explains how the stereotype of the big, strong
Black woman is reaffirmed. While public health campaigns use population-based
study results to identify health risks, in reality not every person who is overweight or
obese will experience chronic illness (Ortega et al., 2013). Through the African
Caribbean lay epidemiological lens, the larger female body which appears to defy ill-
ness through its strength and excess weight is not subject to weakness; therefore, ‘what
is common is right, we presume’ (Rose, 1985). Indeed, it is reported that while Black
women are more likely to discuss the health implications of excess weight and refer to
the health experiences of family members as catalysts for lifestyle change, they also
refer to having a larger body as an advantage because it is ‘less susceptible to illness’
(Shoneye et al., 2011: 538). Thus, African Caribbean women, in common with many
others, will employ a ‘repertoire of health beliefs’ (Davison et al., 1991: 6) that they
can draw upon in various situations to explain health and illness. Perceptions of weak-
ness are also tied to the stereotype of the strong Black woman in relation to seeking
help. A UK study into perinatal mental healthcare found that African Caribbean women
are less likely to seek help from medical professionals for perinatal depression than
other ethnic groups citing the influence of deeply held beliefs of stigma and the impor-
tance of self-control and self-reliance (Edge, 2011). As such, the stereotype of the
Black woman, her body and strength, result in an ambiguous assemblage when health-
care professionals seek to mediate between lay and biomedical discourses and explore
health risks and offer assistance. By implication, healthcare professionals who encour-
age African Caribbean women to view themselves as candidates for obesity and related
chronic illness challenge their lay epidemiological schema (Berthoud and Nazroo,

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Andrews et al. 9

1997). More interestingly, to be deemed a candidate for illness is to go against percep-

tions of independence and strength that form part of the construction of Black feminin-
ity. Thus, within this lay epidemiological framework, a request for weight loss may be
seen as a challenge to perceptions of independence and strength and outside the realm
of the healthcare professional’s legitimacy to intervene.

Stereotyping in the clinic

In this section of the article, we will draw attention to the influences of societal stereo-
types of race and ethnicity that are likely to influence the medical gaze. Acknowledging
that there may be some biological differences between racial and ethnic groups with
regard to what constitutes ‘excess weight’, the discussion will move on to highlight that
the medical gaze assigns specific meanings to body size and weight which may be mani-
fest and explicit, as well as latent and unintended. Healthcare professionals are not
immune to cultural biases and negative stereotypes; this has been confirmed by evidence
of racism within healthcare services both in the United Kingdom and the United States
(Bowler, 1993; Burr, 2002; Green et al., 2007; Lewis et al., 1990; McNeil and Binder,
1995; Sabin et al., 2008). Less obvious, but possibly also damaging to individuals and
groups, are stereotypes of Black women as strong, and possibly aggressive, which may
be contributing factors to decisions about how, when and, indeed, if conversations about
health and weight are initiated.
The BMI continues to be used in measuring and categorising excess weight and has
also become a well-established part of lay discourse about overweight and obesity. When
relating to healthcare professionals, such understandings can result in well-informed
challenges levelled at the legitimacy of the health information that is being given in the
clinic. Kwan (2012) found that participants were able to critique the dominance of the
BMI scale because they saw it as an inaccurate measure of physiological health and fit-
ness in diverse populations and patient groups. The reality of biological differences
between patients allows the healthcare professional and the patient to see ‘race’ without
using racist stereotypes, acknowledging that ‘racial and ethnic differences can also deter-
mine the biological course of certain diseases’ (Epstein, 2007: 216).
However, there may be instances in the clinic where understandings of difference
based on societal stereotypes rather than biomedical knowledge become manifest. In
such instances, the objectivity of the medical gaze is compromised by the social mean-
ings ascribed to racial and ethnic difference. Where African Caribbean women may refer
to stereotypes of Black femininity to figure out health issues, healthcare professionals
may also draw upon stereotypes when working with women from this ethnic group
which influence their care. For example, Bleich et al. (2012) found that obese African
American patients were less likely than obese White patients to be offered advice on
physical activity in primary care consultations. We propose that the stereotypes of
strength and matriarchy of Black women may influence both Black and White healthcare
professionals when raising the issue of weight management with female patients. While
healthcare professionals may have a desire to provide the best care for all patients, it is
possible that the influence of stereotypes may inadvertently contribute to health inequali-
ties through non-conscious racial and ethnic bias (Green et al., 2007; Laird et al., 2007;

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10 Health 

Sabin et al., 2008), which have been shown to become more acute when working under
high levels of work pressure (Burgess, 2010; Van Ryn and Fu, 2003).
Although judgements based on stereotypes made by healthcare professionals may not
be conscious, they are apparent to patients who may be aware of bias during consulta-
tions. This not only compromises relationships between patients and healthcare profes-
sionals, but also affects health outcomes. In their study about self-reported needs of
South Asian women experiencing mental health problems, Chew-Graham et al. (2002)
report that the women were well aware of racist stereotypes regarding them, expressing
concern that healthcare professionals may draw upon these representations during con-
sultations. This concern led them to seek medical attention for mental health issues only
at the point of crisis, rather than when symptoms first became apparent. For Black
women, we propose, it is the perception of strength, tied into racial images of the Black
mammy and the matriarch which may influence when or how health services or advice
are both sought by and offered to them. This suggestion is supported by research which
indicates that in a sample of African American women, self-esteem was affected by neg-
ative and comedic portrayals of larger bodies, both Black and White (Chena et al., 2012).
Lau (2011) found that mainstream pressure of slenderness as the ideal body size and
shape juxtaposed with cultural standards of femininity which affirm larger female body
shapes within African American communities made it difficult for Black women confi-
dently to address their weight management issues and seek medical advice. Additionally,
this particular construction of Black femininity also silences Black women who are liv-
ing with disordered eating conditions such as anorexia nervosa and bulimia nervosa
(Striegel-Moore et al., 2003; Williamson, 1998), which are rarely discussed.
In the final section of this article, we will explore how stereotypical imagery has real
effects not only on health-seeking behaviours by Black women, but also on the interac-
tions in consultations they have with healthcare professionals. Recognising the pressures
under which many consultations and healthcare work are undertaken, we offer some sug-
gestions on how the damaging effects of stereotyping in the clinic might be mitigated.

Implications for practice

Evidence about health inequalities and health outcomes is growing and findings point to
many adverse health effects of stereotyping at both individual and collective level. At
individual level, stereotyping is a strategy for mental shortcuts that guides an observer’s
behaviour towards the other and shapes how they respond to the other’s behaviour (Watson
et al., 1984). It is oriented towards the past and is regressive, depriving what is seen as ‘the
other’ of the freedom to be and do otherwise (Kyoo, 2013). In the case of African
Caribbean women, stereotypical thinking may involve expecting aggressive or angry
responses to the initiation of a dialogue about health and weight and diet, assuming that
African Caribbean women are generally content with their bigger size and would resist
any attempt to raise the issue, and fearing causing offence or being unable to respond to
emotional reactions. If unchallenged, stereotypes become part of all-purpose architecture
of pre-conceptions, assumptions, mental imagery, and generalisations in a strategic
attempt to save time, get things done and mitigate potentially difficult situations. In the
primary care clinic, wider societal issues and discourses shape the interactions between

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Andrews et al. 11

patients and healthcare professionals who face increasing pressures to provide services to
an ageing population with more co-morbidity and complex needs while expectations and
numbers of consultations are rising. It is, therefore, understandable that healthcare staff
make cognitive economies to simplify the complex work of healthcare practice. However,
it also perpetuates a service in which healthcare professionals often remain ill-equipped to
serve the needs of their ethnically diverse patient populations (Mir and Sheikh, 2010).
Aronson et al. (2013) explicitly link stereotyping to discrimination, health inequalities
and poor health for those who are the targets of stereotypes, often those from minority
ethnic groups. They also point to the mounting evidence suggesting its harmful effect at
collective level (Karlsen and Nazroo, 2002; Nazroo et al., 2007). Furthermore, there is a
tendency to ‘pathologise’ minority cultures and their social practices, attributing poor
health and poor health outcomes to aspects of their culture, rather than to structural ine-
qualities and experiences of discrimination (Ahmad and Bradby, 2007). As Atkin and
Chattoo (2007) observe, health inequalities have become enduring, long-term problems
that are only partially resolved, often waiting to be rediscovered in different guises. They
argue that while the focus of research is only on the presence of inequalities rather than
on ways to challenge them, health research may find itself in an analytical cul-de-sac in
which the mechanisms and social processes leading to the production of health inequali-
ties remain unaddressed and potential solutions unexplored.
We suggest that healthcare professionals examine and possibly challenge their own
assumptions and stereotypes about patients from an African Caribbean background,
especially in relation to body shape and size. While many curricula of health profession-
als’ pre- and post-qualification educational programmes already address the issue of
stigma and stereotypes, giving concrete examples, such as the ones we examine in this
article, may serve to deepen an understanding of others’ differences and increase a sen-
sitivity to their needs. This involves a respectful enquiry into a person’s identity rather
than assuming knowledge about the person on the basis of their physical characteristics,
that is, skin colour and size, and signals that the person is seen as an individual in her
own right and not as a representative of a group. Such a recognition and acknowledge-
ment of difference makes it less likely that healthcare staff draw on stereotypes, which
limits dialogue and forecloses possibilities for health promotion that could be explored.
Through this lens, the consultation has the potential to become a ‘liminal space’, a tran-
sitional or border zone between biomedical discourses and lay understandings where
assumptions and pre-conceptions can be tempered and stereotypes suspended. Instead of
obscuring capabilities and strengths through a recourse to stereotypes, such a space ena-
bles dialogue and an interpersonal connection that may be more fruitful in assisting
African Caribbean women and healthcare staff in identifying if and how new decisions
about health could be made. Through engaging in such practice, healthcare professionals
are more likely to foster an environment that encourages them to perceive healthcare
services and advice as accessible and meaningful to them. For African Caribbean women
in particular, who are thinking about making lifestyle changes to reduce health risks, the
healthcare professional who raises the issue in a non-threatening way may provide a
source of support that does not always exist within mainstream social discourse. Rather
than challenging notions of Black femininity, such an approach may be helpful in initiat-
ing lifestyle changes.

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12 Health 

Conclusion
In this article, we have explored how stereotyping in the clinic can threaten social inter-
action between patients and professionals and may contribute to health inequalities.
While the biomedical discourse of health influences the professional clinical gaze and
mainstream understanding of excess weight, oppositional views of the body and other
lay discourses also have significant influence on health behaviours. We have shown how
the social construction of Black femininity has enabled a cultural normalising of excess
weight and obesity in African Caribbean communities. The concept of strength is central
to this. It resists biomedical and mainstream construction of fat and links Black feminin-
ity with notions of physical and emotional strength which are often depicted through
images of the larger Black female body. This representation of excess weight contradicts
mainstream negative views of larger female bodies that portray excess weight as a form
of weakness. We suggest that this notion of strength influences the health behaviours of
African Caribbean women and contributes to shaping interaction with healthcare profes-
sionals in the clinic.
We conclude that by having an understanding that for some African Caribbean women
body size may be linked to strength, healthcare professionals can become aware that by
encouraging weight loss, they may also be posing a challenge to her sense of autonomy
and control. As such, consideration must be given to developing alternative strategies to
encourage health-promoting behaviours rather than pursuing a narrow focus on weight.
A dialogue which starts with identity and cultural resources and not with deficiencies and
problems located in particular ethnic groups has a greater chance of preserving the dig-
nity and integrity of the individual and of building trust and confidence. To what extent
such an approach is both efficient and effective in producing behaviour change and
improved health outcomes is difficult to predict. However, given the importance of the
quality of patient–healthcare professional interactions and the damaging effects of ste-
reotyping on individuals and groups, a critical examination of the aetiology of stereotypi-
cal imagery and the bias it produces in healthcare staff when interacting with the targets
of such imagery is a key starting point.

Funding
This work has been supported by the National Institute for Health Research (NIHR) Collaboration
for Leadership in Applied Health Research and Care West at University Hospitals Bristol NHS
Foundation Trust, and National Institute for Health Research (NIHR) Collaboration for Leadership
in Applied Health Research and Care West Midlands at University Hospitals Birmingham NHS
Foundation Trust. The views expressed are those of the authors and not necessarily those of the
NHS, the NIHR or the Department of Health.

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Author biographies
Nicole Andrews is a Doctoral Researcher in the School of Health and Population Sciences at the
University of Birmingham. Her research area is applied health research with specific interests in
ethnicity, gender and research methods. Her PhD research is concerned with African Caribbean
communities, with particular focus on women. Her work examines how social and cultural factors
may shape health beliefs and influence relationships with healthcare professionals, with a focus on
body shape and size and how they relate to overweight and obesity, and weight management.
Sheila Greenfield is Professor of Medical Sociology in the School of Health & Population Sciences,
University of Birmingham. She is a qualitative methodologist and is experienced in the design and
implementation of qualitative research as a component of mixed methods research. Her major
research interest is in the methods people use to self-manage their health either for health promo-
tion and prevention or for the management of diagnosed medical conditions. She has published
extensively in this area, in particular in the field of complementary and alternative medicine.
Will Drever (MBChB MRCGP) is a GP working in a suburban practice in South Birmingham. A
GP Trainer, Training Program Director on the local GP VTS scheme, and a GP with a specialist
interest in diabetes, he has been involving in commissioning of diabetes medical services, across
south Birmingham, which have included weight management programmes. He was part of the
pilot NIHR CLAHRC in Birmingham investigating community-based care for Type 2 Diabetes,
and more recently he has been selected for a Fellowship of the RCGP in 2015.
Sabi Redwood is Senior Research Fellow in Ethnography and Qualitative Social Science at the
School of Social and Community Medicine at the University of Bristol and qualitative methodolo-
gist for the NIHR CLAHRC West. She has a keen interest in developing ways of understanding
and responding to the complex dynamics of ‘super-diversity’ which have emerged as a result of
increasing social, ethnic and religious diversification through changing patterns of immigration.

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