It’s More Than Hair: Exploring Sociocultural Factors and Perceptions of the Black Hair Salon and the Stylist’s Role in Health Promotion

Abstract

Background: Black women suffer disproportionately from obesity-related chronic diseases, particularly at younger ages. In order to close the gap in these health disparities, efforts to implement culturally appropriate interventions using community-engaged and community-based approaches have increasingly popular in recent years. The hair salon, a community staple for Black women and highly accessible geographically in the U.S., provides increased opportunity for outreach and engagement of multi-level health promotion interventions. Black women regularly frequent the hair salon and oftentimes have long-established relationships with their stylist. This established relationship and routine interaction provides access and opportunity to deliver health messaging and interventions. Hair stylists are well-respected and well positioned to serve as lay health workers in addressing health disparities among Black women in the U.S. Objectives: This dissertation is comprised of three studies: a systematic review of the literature and two qualitative studies; semi structured interviews with hair stylists and focus group discussions with Black women who patron hair salons. The studies sought to address the following three aims to: 1) synthesize the literature assessing obesity-related chronic disease health promotion interventions for Black men and women delivered in U.S. barbershops and hair salons; 2) assess the physical, cultural, and social environment of the hair salon setting as a setting for health promotion among Black women in the U.S.; and 3) assess the sociocultural factors of stylist-client engagement and perceptions about stylist-delivered health promotion. The dissertation was guided by the settings approach theory to better understand the hair salon as a health promoting setting. MethodsA PRISMA-guided systematic review was conducted from October 2019 to February 2020 to identify and critically evaluate health promotion interventions for Black men and women delivered in barbershops and hair salons. Six databases (Academic Search Ultimate, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Embase, PsycINFO, PubMed, Web of Science (Science Citation Index and Social Sciences Citation Index)) were searched for eligible studies. Data were extracted and quality of evidence was assessed in duplicate. Experimental and quasi-experimental studies for adult (> 18 years) African Americans delivered in barbershops and hair salons that evaluated interventions focused on risk reduction/management of obesity-related chronic disease: cardiovascular disease, cancer, and type 2 diabetes were included. Primary data collection for qualitative interviews included semi-structured interviews and focus group discussions. Semi-structured interviews of hair stylists who service predominately Black women were held from October to December 2020 and focus group discussions with Black women who routinely received haircare services from a licensed hair stylist were held on February 20th and 27th 2021. For Aim 2, stylists’ and clients’ perceptions of the physical, cultural, and social constructs within the settings approach theory were assessed, while Aim 3 explored the extent hair stylists influence their Black female clients and clients’ preferences for their stylist’s role in salon-based health promotion programming. Thematic analysis of the data was conducted in an iterative, multi-step process. Results The systematic review yielded 14 studies that met the inclusion criteria. Most study interventions (n=10) were delivered in a barbershop with the remaining (n=4) were in hair salons. Intervention components, study designs, and outcomes vary widely across studies. Cancer was the most studied disease state followed by hypertension (n=7, 50%; n=5, 35.7% respectively). Behavior change was the focus of most interventions (n=10) while four studies reported clinical outcomes. Among study participants for Aims 2 and 3, stylists (n = 30) were predominantly Black (96.7%), women (83.3%); clients (n = 39) had at least a 4-year college degree (89.8%), insurance (92.3%), and a primary care provider (89.7%). Regarding Aim 2, there was concordance between stylists and clients that the physical environment does not support healthy eating behaviors; the social environment is a source of information exchange and social support; and the cultural environment embodies a “safe” space for Black women. Findings for Aim 3 suggest clients are influenced by stylists they perceive as trustworthy, relatable, and credible. Trust, relatability, and credibility were deeply linked to racial and gender congruence. Clients are more likely to be receptive to stylists that model healthy behaviors and deliver health promotion only in the context of a hair-health connection. Stylists ‘triaging’ and referring to healthcare professionals for follow up was preferred by clients. ConclusionsHealth promotion interventions delivered in barbershops and hair salons are effective for promoting cancer screening and managing hypertension among Black men and women. More studies are needed that focus on diabetes and obesity and utilize the hair salon as a site for intervention delivery. Understanding the physical, social, and cultural environments of the hair salon can inform the design of salon-based, rather than salon-placed interventions. Recognizing the context and degree of stylist influence and clients’ perceptions of stylist-led health promotion programs can help researchers and public health practitioners leverage hair stylists’ role in health promotion as lay health workers.