Hair Stylists as Lay Health Workers: Perspectives of Black Women on Salon-Based Health Promotion

Highlights

What do we already know about this topic?

Hair stylists are willing to serve and have been utilized as lay health workers.

How does your research contribute to the field?

This research illuminates Black women’s perceptions of hair stylists’ influential qualities and acceptability of hair stylists engaging in health promotion.

What are your research’s implications towards theory, practice, or policy?

This research provides considerations and context for utilizing hair stylists in health promotion for Black women to optimize intervention outcomes and implementation.

Introduction

Lay health workers (LHWs) are members of a community who perform functions related to health care delivery such as health education, patient navigation, health promotion, and support for health behavior change. ¹ Traditionally, they do not have formal, “professional” training or education beyond the scope of the intervention for which they are involved. As members of the target community for which an intervention is designed, they bridge the gap between healthcare systems, intervention programs, and vulnerable, underserved communities. ¹ The use of LHWs have become increasingly popular in efforts to reduce health disparities among underrepresented racial and ethnic populations. LHWs have been effective in health promotion programs ranging from improving health literacy, ² increasing access to care, ³ and impacting health behavior change. ⁴

Specifically, initiatives to address health disparities among Black women have adopted the LHW model. Utilizing trusted members of the Black community such as church pastors as LHWs has been effective in health promotion and education efforts. ⁵ Building upon the success of pastor-led, church-based health promotion, hair stylists have been enlisted to host health promotion and provide health education for their clientele. Black women routinely patronize the hair salon oftentimes receiving services from a particular stylist for years. This established relationship and regular interaction provides access and opportunity to deliver health messaging and interventions. While hair salons often serve as program recruitment sites,^6-9 it has been demonstrated that involving the stylist in select interventions can enhance program effectiveness.^4,10-13 Stylists have been described as “natural helpers” who have a unique and close bond with their clients making them well positioned to serve as LHWs. Soloman and Linnan ¹⁴ observed that health topics such as diet, weight management, and reproductive health were commonly discussed among stylists and clients. Also it has been documented that stylists are interested in, and comfortable with, discussing health issues with their clients. As a result, researchers and programmers have assessed stylists’ interests in health promotion activities from willingness to host programs ¹⁵ to health topics of interest ¹⁶ to strategies for delivery.^10,17,18

Most stylist-led health promotion research to date has focused on stylists’ willingness and interest to serve as LHWs. Little is known about the acceptability of salon-based health promotion using stylists as LHWs from the perspective of Black female clients. Further, there are no studies that elucidate the level and context of influence stylists have on their clients that could impact receptivity of stylist-delivered health promotion program and ultimately implementation. To that end, the purpose of this qualitative study was to explore to what extent hair stylists influence their Black female clients and clients’ preferences for their stylist’s role in salon-based health promotion programming.

Methods

Study Design

We employed a qualitative descriptive design to better capture information directly from constituents that may not be conveyed in a survey or other quantitative data. Focus group discussions (FGD) were the preferred chosen methodology for collecting data by leveraging group dynamics to get the views, opinions, and experiences of as many individuals as possible. The FGD guide was informed by an extensive review of recent literature on stylist-engaged health promotion, and domains of importance as determined by research team members who identify as Black women (Authors 1, 2, 3, 5, 6). FGD questions (Table 1) focused on clients’ perceptions of stylist influence, stylist identity and its impact on relations (e.g., conversations, advice, etc.), and stylist’s role in health promotion. Additional probing questions were included to facilitate further discussion. Table 1 provides sample questions and probes from the moderator guide.

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Table 1.

Sample Interview Guide Questions and Probes.

Topic	Sample Questions and Probes
Getting started	Tell me about your stylist?  What do you like about them?
Stylist identity	How does your stylist’s age/gender/race/ethnicity impact your relationship?  How does it impact your interactions?  How does it impact the types of conversations you have?
Stylist influence	What influence does your stylist have on you?  What kinds of things do you seek/take advice from your stylist on?
Stylist role in health promotion	If your stylist was involved with a health promotion program, as a client, what would you be receptive to?  How would you feel about your stylist talking to you about health topics?  How can stylists help improve or support the health of their clients?

Results

Eighty-one individuals consented to participate with 57 scheduling for a FGD. Scheduling conflict was the only reason given by those that notified the research team that they would not be able to attend their scheduled FGD. Eight FGDs were held with a total of 39 women (average of 5 per group) residing in the Eastern, Midwestern, Southern, and Southwestern regions of the U.S (Figure 1). Most clients had a college degree (89.8%), health insurance (92.3%), and a primary care physician (89.7%). While most rated their health as very good or excellent (66.7%), over half (56.4%) reported being diagnosed with a chronic condition (e.g., hypertension/high blood pressure, mental health condition, prediabetes/Type 2 diabetes, asthma, cancer, other). Demographic characteristics of participants are presented in Table 2.OPEN IN VIEWER

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Table 2.

Participant Demographic Characteristics (N = 39).

Demographic Characteristics	Clients (N = 39) (%)
Age
18–24	2 (5.1)
25–34	5 (12.8)
35–44	15 (38.5)
45–54	11 (28.2)
55–64	1 (2.6)
≥65	5 (12.8)
Gender
Male	0
Female	39 (100)
Ethnicity
Hispanic	0
Non-Hispanic	39 (100)
Race
Black/African American	39 (100)
Native American/Alaska Native	0
Asian American/Pacific Islander	0
White/European American	0
Education level
≤ High School	0
Some college or 2-year college degree	4 (10.3)
4-year college degree	12 (30.8)
≥ 4-year college degree	23 (59)
Insurance status
Yes	36 (92.3)
No	3 (7.7)
Primary care provider
Yes	35 (89.7)
No	4 (10.3)
Self-rated Health
Excellent	3 (7.7)
Very good	23 (59)
Good	11 (28.2)
Fair	2 (5.1)
Poor	0
Chronic condition
Prediabetes/type 2 diabetes	4 (10.3)
Hypertension/high blood pressure	12 (30.8)
Cancer	2 (5.1)
Asthma	4 (10.3)
Mental health condition	5 (12.8)
Other	4 (10.3)
None/not applicable	17 (43.6)

Below we present themes emerging from participants’ perceptions of their stylist’s influence on their lives—the context and degree of influence; the impact of stylist identity (age, gender, and race) on influence and interaction, and preferences for their stylist’s involvement in salon-based health promotion. In some instances, identified themes applied to multiple domains or subdomains of interest.

Discussion

Hair stylists can play a central role in health promotion and education for Black women in the U.S., but until now clients’ perspectives of factors of influence and stylist involvement have not been explored. To design and implement an effective health promotion program, consideration must be given to understanding the recipients’ perceptions. To our knowledge, this is the first qualitative study exploring clients’ perceptions of the level and degree of influence hair stylists have on their clients; what factors lend themselves to such influence; and in what context stylists should engage in salon-based health promotion. This study highlights significant findings in the emerging literature on the use of hair stylists as lay health workers in the Black community.

First, these findings confirm that trust is a significant factor for engaging with Black women and hair stylists are trusted members of the community.^22,23 Trust between a Black woman and her hair stylist is built over time, through the frequency and regularity of service visits, and demonstrated “successful” outcomes. Gender and racial congruence for participants was profound and centered on trust and relatability. Also, participants’ perception of stylist’s credibility was inherently linked to the profession but reinforced by the stylist’s age. When it comes to health promotion consideration must be given to who is communicating health information that is relevant to Black women. Black women may not be as comfortable talking to men or non-Black stylists about certain health topics.

Also, there is opportunity in targeting hair stylists first as the recipient of health behavior interventions. Clients may be more accepting of health promotion and education from stylists who have gone through an intervention themselves and can serve as peer coaches. Barbers have served as peer coaches for interventions related to smoking cessation while hair stylists have been involved in peer coaching interventions for contraception and chronic kidney disease awareness. ²⁴ The major limitation of these interventions and others (e.g., STD/HIV awareness) is the barbers/stylists did not participate in an intervention themselves. ²⁵ A recent article highlighted occupational hazards (e.g., inability to eat healthy while working) of hair stylists that may prevent them from engaging in health promotion. ²⁶ This lack of intervention for stylists limits their ability to model desired behaviors for their clients. Capitalizing on this preference for role modeling, interventions that target hair stylists and their personal health conditions can set the stage for a “domino effect” that can reinforce a health promotion intervention.

Another important finding, is despite well documented interest of hair stylists to participate in salon-based health promotion, there was mixed feedback regarding the appropriateness of stylists’ involvement. ²⁷ Clients’ beliefs regarding the appropriateness of stylists talking about various health topics particularly those not directly related to hair warrants further consideration when designing salon-based health promotion programs. However, clients did perceive stylists as playing a role in their emotional well-being which poses additional opportunity for mental health interventions. Employing hair stylists and barbers to bring awareness to and even intervene on mental health issues in the Black community, using a theoretical model known as “PsychoHairapy” has been proposed by Mbilishaka.^28,29 The level and amount of physical touch and close contact involved in Black women’s hair care services supports the notion of intimacy and nurturing clients feel from stylists.^30,31 Barber-led mental health interventions have been utilized successfully. ³² Despite the abdundance of literature that supports the unique bond of hair stylists and Black women and the evidence for mental health interventions delivered in barbershops for Black men, there have been no stylist-led mental health interventions designed for Black women.

Clients’ receptivity to health messaging and intervention effectiveness may be impacted by a stylist’s role in the intervention delivery. In a systematic review, interventions that were led or supported by a barber or hair stylist had a positive impact on both intervention effectiveness and feasibility. ¹³ When barbers and stylists were trained on intervention content and delivery, there were high levels of implementation, satisfaction with the intervention by clients, and intention to continue with the intervention beyond the study. ¹³ Studies that linked intervention delivery to a clinical partner reported significant positive results. ¹³ In another study, barbers who went through training to deliver information on prostate cancer screening to their clients, had significantly higher levels of prostate cancer knowledge post-training. ³³ Providing trainings for stylists (with documentation/certification), supporting materials from professional health organizations, partnering with health professionals, and capitalizing on stylists’ professional expertise by linking hair/skin/scalp health to other health issues can possibly enhance clients’ receptivity to stylists as lay health workers and warrants further investigation.

A potential limitation of this study is the participants in this study had higher levels of education, were insured, and had access to a primary care physician. Given these variables, it is within reason to question the generalizability of the study findings. This affluent study sample may be due to the recruitment methods employed that targeted social media groups of Black women who are members of the National Pan-Hellenic Council and women who work in public health-both consisting of college-educated Black women. However, it is also important to underscore that despite the majority reporting high levels of self-rated health, most of the study participants had been diagnosed with a chronic disease, and chronic disease disparities for Black women persist despite higher socioeconomic status.^34,35 And while our sample was geographically representative, we recommend future exploration of clients’ perceptions of stylist-led health promotion include greater socioeconomic distribution to address potentially variable opinions by education across clients.

Conclusion

This study presents a platform from which future development of acceptable health promotion programs delivered by hair stylists, perhaps through partnering with health professionals for training, resources and/or expertise may be based. Health promotion researchers and programmers should utilize community-based participatory research (CBPR) approaches to solicit input from stylists and clients alike in relation to the development of effective programming. When designing interventions, CBPR can facilitate collaborations to 1) identify the scope of health promotion that is acceptable when delivered by stylists, 2) describe clients’ health topics of interest, 3) start with the development of health education materials with a hair-health connection in consultation with stylists and/or dermatologists, and 4) consider additional partnerships with healthcare providers to provide a clinic-community linkage in program delivery. This study illuminates the importance of exploring the perceptions of clients to improve the design, implementation, and evaluation of salon-based, stylist-led health promotion interventions.