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

Lay health workers (LHWs) have been effective in delivering health promotion to underserved, vulnerable populations. Hair stylists are well positioned to serve as LHWs in addressing health disparities among Black women in the U.S. The purpose of this qualitative study was to explore the extent to which hair stylists influence their Black female clients and clients' preferences for their stylist's role in salon-based health promotion programming. Eight virtual platform focus groups were conducted with Black women (n = 39) who receive hair care services from a licensed hair stylist across the U.S. Most participants had a college degree (89.8%), health insurance (92.3%), a primary care provider (89.7%), and the majority had at least one chronic disease (56.4%). Participants reported higher potential for influence related to level of trust in the stylists and for stylists they find relatable and credible. Trust, relatability, and credibility were further determined by racial and gender congruence. Client interviewees felt stylists should model healthy behaviors and reported they may not be receptive to stylist-delivered health promotion out of the context of a hair-health connection. In this sample of well-educated clients, there was an expressed preference for stylists to provide referral to healthcare professionals or solicit experts for health topics out of the scope of haircare rather than guide the health promotion efforts themselves. Findings from this study can inform future development of acceptable salon-based, stylist-led health promotion programs that partner stylists with health experts to deliver 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. 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. 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, increasing access to care, and impacting health behavior change.

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. 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 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 to health topics of interest 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.

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?

Participants

Eligible participants were Black women, age 18 and older, who receive haircare services from a licensed hair stylist. The sample size was determined by thematic saturation, when new data no longer offered additional insights for the research question. A homogeneous sample was recruited primarily via social media. Study recruitment announcements were posted to the PI’s (Author 1) social media pages and in groups geared towards Black women (National Pan-Hellenic Sororities, Black Ladies in Public Health, Black Sistahs Making Friends, etc.), and groups related to Black women’s hair (hairstyles, haircare services, etc.). To garner a geographically representative sample, social media sites/groups representing cities across the U.S. were targeted (DFW Hair Game, Atlanta Black Hair Styles, etc.). The advertisements described the study purpose, involvement and time commitment, compensation, and eligibility criteria. Eligible and interested individuals provided electronic consent, completed a demographic survey via REDCap, and then registered for a FGD session through the Calendly online scheduling site (https://calendly.com). The study was approved by the University of Arizona Institutional Review Board (protocol number 2007888863).

Data Collection

FGDs were conducted and recorded on February 20th and 27th 2021 via the University of Arizona Zoom platform (http://arizona.zoom.us). FGDs were led by the first author, a doctoral student (at the time of data collection) who is a Black woman with extensive experience in qualitative interviewing. Another doctoral student (Author 2), a Black woman who is a physician and has experience in medical interviewing, served as co-facilitator and note taker. The facilitators introduced themselves to the participants, discussed their interest in the research topic, and went over the informed consent at the start of the FGD. Participants provided oral informed consent and were given the option to use the video or the phone-in feature. FGDs lasted 1–1.5 hours. After each FGD, the interviewer and note taker summarized brief notes to gather overall impressions and participants received $25 for their time. Notes were recorded in REDCap. Audio recordings were professionally transcribed through Rev (https://www.rev.com), a web-based transcription service, and checked against the original audio recordings for accuracy. Transcripts were not returned to participants for comment or correction to maintain confidentiality.

Data Analysis

Data were thematically analyzed in a multi-step process. Transcripts were first reviewed by 2 members of the research team (Authors 1 and 2) independently. During the familiarization step, brief notes were taken and excerpts were summarized. An initial codebook was developed by 3 of the authors (Authors 1, 2, 3) using the DEDOOSE web application to code and organize the data. Each transcript was blind coded in duplicate by 2 of the authors (Authors 1 and 2). The 2 coders met to discuss discrepancies and the codebook was further refined and finalized. Codes from the data set were collated by the DEDOOSE software analytics tools. Themes were identified and finalized by 2 authors (Authors 1 and 3) when consensus over thematic saturation was reached. We did not solicit participant feedback on the codes and final themes and sub-themes identified.

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.

Figure 1.

Geographic Representation of Participants (Zip Code).

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.

Trust

The theme of trust was pervasive throughout our discussions. Trust shaped the level of influence stylists have over clients’ lives. The dimensionality of trust was described as either acquired based on professionalism or instrinsic based on stylist characteristic(s). Stylists foster trust by providing exemplary haircare services. Once trust is established, clients are receptive to guidance from their stylist in other areas of their lives.

“I trust my stylist’s opinion and her advice. She gives good, um, she gives me suggestions on what hairstyles I should get and how I should take care of my hair. And she also gives me financial advice from time to time. So, I trust what she has to say.” C287

“You have to have a certain amount of trust in that person to even let them do your hair. And that trust for me, translates over into other areas, but I would at least listen, consider, and potentially try something that she suggests.” FGD2

While participants felt strongly that trust is earned, an inherent trust that comes from gender and racial congruence was also noted. This trust extended beyond the ability of a stylist to care for hair textures associated with Black women to comfortability interacting and engaging with a stylist that was not a Black woman.

“I have gone to a man before for hair care when my hair was straight and he did a wonderful job, but yeah, I’ll automatically trust a Black woman before anything.” C93

“I really don’t feel comfortable with another race or a gender on my head. So, I would say, no. I just would not feel comfortable even being able to trust the conversations that we may have. And can we have decent conversations as far as race is concerned, race relations, anything like that, if they weren’t a Black person?” C34

Relatability

Interrelated with trust was the theme of relatability. For clients, stylists that shared the same gender and/or racial identity could better relate to issues Black women face. The theme of relatability mostly centered on preferences for race and gender. As one participant stated:

“I mostly was looking for someone that looked like me because I feel like I would trust them. And in that they would innately understand the Black woman’s experience.” C93

Participants discussed how their interactions were impacted by stylist’s gender. Some clients noted male stylists were either not as engaging or conversations were limited to “surface-level” topics such as local activities/events, fashion, or relationships.

“My relationship with him, it was cool, but I still feel more comfortable having a female stylist, I guess because we can relate on so many different levels and it’s easier to talk to her. He was easy to talk to you too. Don’t get me wrong, but it was just different, you know.” C209

Most participants felt strongly about their preference for a Black woman stylist. Clients were more inclined to take advice from stylists that are Black women not only related to hair, but on other topics as well. They mentioned shared lived-experiences, unique to Black women, as vital to establishing a deeper relationship.

“I do prefer, um, an African American woman. I do feel a, more of a connection and I can talk more about other things than just hair and you know, about, you know, how life is even affecting my hair.” C41

“I’ve always had Black stylists and she’s a woman. I don’t know if it will make a difference, but I know what a Black woman, if I’m talking about certain things, she relates to them and can give an insight.” C164

One participant, who receives hair care services from a White woman spoke about the differences in how interactions play out in the salon setting. She highlighted that her stylist is unable to relate to issues in the Black community and consequently is disengaged from such conversations.

“So, when other people are in and we’re talking about general things in the Black community…. she can’t contribute to the conversation. She doesn’t fit in… she can’t add to the conversation.” C30

Credibility

Participants acknowledged that stylists are professionals and therefore yields a certain level of credibility. Clients value stylists’ “professional” opinion and as a result give consideration to their recommendations and referrals.

“I think people find them credible…. they’re a professional so to me, it makes them credible. And [if] they suggest someone to come in and discuss a product or have a pamphlet about anything they feel strongly about they’re kinda vetting to have in their salon, I would think that whoever is pushing a product or, some type of service would find the referrals of a salon owner a good avenue to get people who will be probably loyal to their products because it’s a bond that you don’t really get a lot of other places.” C346

“[She’s a professional] I think there’s probably not a thing that [she] could not recommend to me that I wouldn’t at least, look into.” C446

Credibility was also associated with a stylist’s age. Clients described relationships with stylists that were older as “maternal” in nature or that of an “aunty” or “older sister.” Some clients felt they could talk to stylists who were older about life experiences and seek advice. Younger stylists were sometimes described as less mature and/or and leaving clients less inclined to respect their opinion.

“With the older women I tended to lean on their wonderful, fantastic life experience and, sort of what they thought about their historical perspectives and points of view.” C446

Role Model

Clients felt it is important for their stylist to model desired behaviors. For clients, it is not enough for stylists to “talk the talk,” but to also “walk the walk.” Clients are more likely to “buy-in” to recommendations and take advice from their stylist if their stylist is engaged in the behavior themselves. Participants noted that it would not feel genuine for their stylist to promote something that they themselves were not actively participating in.

“My hairstylist is really big into diet and eating habits. She’s recommended a couple of cleanse and food products to me that I take her recommendations about. And I mean, recommend them to me, not based on my hair, but just based on what she does personally for herself.” C317

“My beautician is pretty healthy, like I can tell that she works out and things like that. So, just in my personal journey to be the best at 40 in a couple of months asking her questions about what her workout routines are, things that have worked for her; health, diet, things of that nature, since it’s obvious that she takes care of her body and her skin.” C386

Role with Health Promotion

When reflecting on their preferences for stylist involvement in health promotion programming, participants acknowledged the “natural” role hair stylists already play. Participants discussed how stylists have been informally promoting health particularly as “therapists” or counselors” while listening to the concerns of their clients.

“Stylists for so long have been, support from a mental perspective, like, you know, you go to the salon, and you just are able to have a conversation about a myriad of things. They already are almost like a behavioral health or a mental health resource.” C93

However, while participants reported talking to their stylists about their personal health conditions, many did not believe their stylist should deliver health messaging about chronic diseases unless it was linked to hair. Doing so was deemed out of the scope of the stylist’s expertise. Clients were not opposed to stylists serving in a “triage” capacity and making a referral to a healthcare provider for follow up or having an expert present in the salon to defer to.

“I would say that if it’s coming out of the mouth of the stylists, and they’re providing some guidance, that it would make more sense for it to be tied to my hair, skin or nails. But I don’t think that means that if they were also guiding me to another expert, about another thing that I wouldn’t feel good about that, right? I don’t necessarily want my hairstylist to be telling me about how to manage diabetes, because that doesn’t make sense to me. But I think when you look at health disparities in the health of our community, we might be overestimating how often people go to the doctor. I go to my doctor all the time. So, I don’t need my hairstylist to talk to me about that, personally. But if we’re looking at the broader picture of our community, people are going to the hairstylist and they’re not going to the doctor, I promise you that. So, if our hairstylist could say, " when’s the last time you went to the doctor?" You don’t have to tell ‘me’ about diabetes, but encouraging our people to go to the doctor, if that’s where that information should be coming from, I think would be an appropriate use of that platform.” C284

Participants also talked about the limitations of stylists engaging in salon-based health promotion. Participants shared their experiences with stylists having various backgrounds, education levels, levels of professionalism, and the balance of altruism and profit. Not all stylists are perceived by clients as compatible to serve as lay health advisors.

“I think that there has to be a, just a certain standard, and not saying that no one, isn’t professional, but I think that there has to be a certain level of professionality amongst the stylist for you to even present this information to them. And even though this all sounds great, we do have to acknowledge the fact that this is not something that every stylist is going to be able to, to be best suited for.” C1

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. The major limitation of these interventions and others (e.g., STD/HIV awareness) is the barbers/stylists did not participate in an intervention themselves. 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. 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. 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. 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. 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. Studies that linked intervention delivery to a clinical partner reported significant positive results. 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. 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.