African American Women, Hair Care, and Health Barriers

Raechele Cochran Gathers, MD; Meredith Grace Mahan, MSc
Multicultural Dermatology Center, Department of Dermatology, Henry Ford Hospital, Detroit, Michigan;
Department of Biostatistics and Research Epidemiology, Henry Ford Hospital, Detroit, Michigan

Disclosure: The authors report no relevant conflicts of interest.

Objectives: The objective of this study was to elucidate the prevalence of hair loss among African American women; explore the psychosocial impact of hair grooming difficulties; and examine both perceptions related to physician encounters in this group and the relationship between hair grooming, physical activity, and weight maintenance. Design: An anonymous retrospective and qualitative survey, the Hair Care Assessment Survey, is an 18-question novel survey instrument designed at the Henry Ford Hospital Department of Dermatology Multicultural Dermatology Center. Setting: The Hair Care Assessment Survey was distributed at church-related functions at predominantly African American metropolitan Detroit churches. Participants: Two hundred African American women from metropolitan Detroit, Michigan, aged 21 to 83. Measurements: The Hair Care Assessment Survey collected data relating to hair loss and hair care, psychosocial experiences relating to hair loss, and hair care as it relates to exercise and body weight management. Data was collected on doctor-patient hair-related medical visits and experiences with commercially available ethnic hair care products. Results: More than 50 percent reported excessive hair loss. Twenty-eight percent had visited a physician to discuss hair issues, but only 32 percent felt their physician understood African American hair. Forty-five percent reported avoiding exercise because of hair concerns, and 22 percent felt that their hair impeded maintaining healthy body weight. Conclusion: Hair loss affects a compelling number of African American women, and a significant number express dissatisfaction in hair-related physician encounters. Additionally, hair styling problems present a serious impediment to physical activity and weight management among this already high-risk population.
(J Clin Aesthet Dermatol. 2014;7(9):26–29.)

While hair loss among African American women is exceedingly common,[1] there is limited epidemiological data. Alexis et al[2] reported alopecia as the fourth most common diagnosis of African Americans presenting to the dermatologist, accounting for 8.3 percent of visits.

The most common hair and scalp complaints among African Americans include hair breakage, scalp itching, excessive dandruff and flaking, and hair loss at the crown and temples.[3] Hair care products popular among African American women, including emollients, colloquially referred to as “hair grease,” gels, spritzes, and relaxers have been implicated in hair fragility and loss.[1]

The goal of this project was to further characterize hair loss among African American women, including the psychosocial and physical impact of hair grooming difficulties. Further, the authors explored the penetrance of chemical hair services among African American women and their subjective experiences with both physicians and the hair care industry in relation to hair and scalp concerns and the perceived viability of currently available hair grooming products, respectively.

The authors performed an anonymous retrospective and qualitative survey of African American women in the metropolitan Detroit area to characterize their experiences with hair loss, hair grooming difficulties, and hair-related physician encounters. The Hair Care Assessment Survey (HCAS) was distributed to 200 African American women at church-related functions at metropolitan Detroit churches during the summer and fall of 2011. The survey was developed at Henry Ford Hospital Department of Dermatology and was a single page, taking less than 10 minutes to complete. This research was approved by the authors’ institutional review board (IRB No. 6884).

Survey instrument. The HCAS is an 18-question novel survey instrument designed to collect data regarding history of hair loss and hair care problems, psychosocial experiences relating to hair loss and hair care, subjective data on hair in relation to exercise and body weight management, subjective experiences relating to doctor-patient encounters during hair-related medical visits, and experiences with commercially available ethnic hair care products. The HCAS also collected data on current hair styling, specifically chemically treated versus non-chemically treated (natural) hair, and popular views on African American hair styling as a marker of beauty. The only demographic data collected was age and race/ethnicity.
Data analysis. All analyses were done using SAS 9.2. Continuous data were presented as mean, standard deviation, median, minimum, and maximum, and categorical data were presented as counts and percents. All survey responses were compared between those with natural and straight hair using a two-group t-test for age and using either chi-square or Fisher’s exact tests for all categorical variables. Statistical significance was set at p<0.05.

There were 200 HCAS surveys collected. The mean age of survey respondents was 51.1 years, though seven respondents declined to give their ages. All respondents were women, with 98 percent reporting as African American, and two percent reporting as biracial (mixed with African American) (Table 1).

Hair loss. Fifty-nine percent of respondents reported a history of “excessive” hair loss, defined as excessive breakage or shedding, either at present or at some time during the past (Table 2). Forty-four percent reported having suffered from an excessively itchy or scaling scalp.

Hair. Subjective experiences. Just over a third (34 percent) of respondents felt that their hair was unhealthy. Seventy-four percent reported that they had felt frustrated by their hair, and 41 percent reported that their hair had made them feel bad about themselves. Nearly half, 47 percent, reported that they had felt embarrassed by their hair.

Hair care, physical activity, and weight management. Nearly half of respondents (45%) reported that they had avoided doing physical exercise for fear of “messing up” their hair (Table 2). Twenty-two percent felt that their hair prevented them from maintaining a healthy weight (Table 2).

Doctor-patient interaction. Twenty-eight percent of respondents reported having discussed their hair and/or scalp issues with a physician, and the majority (68 percent) felt that their doctor did not have a good understanding of African American hair (Table 3).

Commercial hair care products. With regard to hair care products marketed toward African Americans (often termed “ethnic hair care products”), approximately half of respondents (52%) felt that hair care companies provided good products for African Americans. Ninety-four percent felt that hair care companies should still do more research to find out how to make African American hair healthier.

Hair styling choices and beauty. While the majority of respondents (60%) wore their hair chemically straightened (relaxed), a significant number (40%) reported having non-chemically straightened (natural) hair (Table 2). Of the 110 respondents who had chosen to wear their hair in a straightened style, 88 percent reported that they felt that natural African American hair was attractive, and 61 percent reported that at some time in the future they might consider wearing their hair in its natural state.

Negative correlation. There were no statistically significant differences in experiences with hair loss, psychosocial experiences with hair, hair and physical activity, or in encounters with doctors or ideals about the ethnic hair care industry between women who reported wearing their hair chemically straightened and those who did not. The only statistically significant difference between the two groups of women is that women with straightened hair were significantly less likely (61 vs. 82%; p=0.023) to consider wearing a natural hair style in the future.

A majority of respondents (59%) reported a history of excessive hair breakage or shedding, and 44 percent reported a history of excessively itching and scaling scalp. The innately more fragile African hair shaft,[4] combined with processing and infrequent washing, can lead to problems with hair breakage and dry and inflamed scalp.

Nearly three quarters (74%) of respondents reported that they had at some time felt frustrated by their hair. In a study of androgenetic alopecia, Van der Donk et al[5] reported that 75 percent of women with androgenetic alopecia manifested negative self esteem, and half reported social problems. Some practitioners, unfamiliar with race-related differences in hair structure, care, or disease, may mistakenly “trivialize” the patient’s hair loss concerns—in either words, body language, or attitude.[6] Such marginalization should be strictly avoided, not only because of the psychological impact of the hair loss, but also because many causes of alopecia and scalp disease in this population are treatable with proper medical management and patient counseling.

Forty-one percent of respondents reported feeling bad about themselves because of their hair, and nearly half (47%) reported that they had been embarrassed by their hair. These subjective concerns are significant, especially considering that depression represents a considerable health burden for African American women, with one-year prevalence rates of depression reported from 2.2 to 3.1 percent. In addition to economic stressors and negative life events, low self concept has been shown to contribute to depression and mood-related symptoms.[7]

Itching and scaling scalp were also a significant concern among respondents, with 44 percent reporting a history of excessive itching or scaling. These symptoms, assumed to be seborrheic dermatitis by proxy, have been previously reported to be of significant concern among African Americans. Alexis et al[2] reported that seborrheic dermatitis was the fifth most common reason for African Americans to come to the dermatologist. Similarly, in a survey of scalp disorders and hair care practices among African American girls, Rucker-Wright reported that seborrheic dermatitis was the most common scalp disorder in African American girls aged 1 to 15, affecting 33 percent of respondents.[8]

Hair care issues are more frequently being recognized as a barrier to exercise in African American women. In a survey of overweight African American women (body mass index [BMI]  ?27.3), nearly one-half of respondents stated that hair care issues affected when and how long they exercised.[9] Similarly, in a focus group analysis of African American women who had struggled with weight loss and body weight maintenance, the issue of hairstyle management was a major theme. Exercise avoidance was cited as a way to overcome hairstyle challenges related to physical activity.[10] In another study, many African American women reported that they felt that they had to make a conscious decision to sacrifice their hairstyle for the sake of physical activity or had to plan their salon days just before the off days in their exercise regimen.[11] A recently published survey study found that nearly 40 percent of African American women have avoided exercise secondary to hair care concerns.[12] Previous studies have indicated that hair care maintenance activities (e.g., flat iron, perms [relaxers], frequent visits to the beauty salon) are a strong motivating factor for limiting or avoiding exercise. These hair maintenance activities are both costly and time consuming, and are generally lessened if physical exercise is limited.[13] Forty-five percent of respondents reported avoiding physical exercise due to hairstyle concerns. The public health impact of limiting exercise due to hair styling cannot be minimized, with 78.2 percent of African American women aged 20 years or older classified as overweight and nearly half (49.6%) classified as obese. These rates of overweight and obesity among African American women exceed those for non-Hispanic Caucasians, Mexican Americans, and all Hispanics.[14]

It is interesting, though, that only 22 percent of respondents felt that their hair kept them from maintaining a healthy weight, especially since physical activity is so closely linked to weight maintenance. This relatively low number may be explained by the fact that some respondents may not recognize themselves as overweight. Data indicated that African American women mistakenly perceive a higher BMI cutoff for “overweight” when compared to non-Hispanic Caucasian women.[15] In a study comparing racial differences in perceived weight status, obese African American women were more than three times as likely as Caucasian women to misperceive their weight. This tendency may be related to heavier body image ideals, fewer social pressures to lose weight, and/or a lack of awareness about the clinical thresholds of overweight and obesity.[16]

A significant number of respondents (40 percent) reported wearing natural (not chemically relaxed) hair. This number was surprising, as it contradicts prevailing beliefs and reports that between 70 to 80 percent of African American women relax their hair.[6] However, recent marketing reports confirm that the number of African American women who do not chemically relax their hair is increasing. In 2011, 36 percent of African American women reported wearing non-chemically relaxed hair, up from 26 percent in 2010. Similarly, relaxer kit sales dropped 17 percent between 2006 and 2011.[17] These figures may herald a welcome change, as women with natural hairstyles are more likely to engage in vigorous physical activity, and thus may enjoy a more optimal body weight. Having a straightened hair texture may not be “exercise friendly” and may have both conscious and unconscious effects on the decision to avoid exercise.[9] Indeed, in one study, women with relaxed hair were more likely to avoid exercise because of their hair.[12] Among hairstyling strategies reported to be a solution to exercise-related hair concerns, natural hairstyles (afro styles) have been reported as a viable option.[10,12]

One barrier to embracing natural hairstyling may be unfamiliarity. Many African American women begin having their hair chemically straightened as young girls, and thus never have the opportunity to learn to care for their hair in its natural state. Rucker-Wright reported that 41 percent of African American girls aged 1 to 15 wore relaxed hair, and 46 percent had their first relaxer between ages 4 and 8.[8]

A final area that deserves further exploration are the experiences that our respondents reported when discussing their hair and scalp concerns with a physician. Twenty-eight percent reported that they had visited a physician to discuss hair and scalp concerns. Of these, 68 percent did not feel that their doctor understood African American hair. While there are no known reports on the subjective confidence of physicians in treating African American scalp disease, the adage that “perception is reality” indicates that there is significant work to be done in the arena of physician education when it comes to both the morphology of African American hair and the grooming habits popular among African Americans. It is estimated that by 2050, people with skin of color will make up the majority of US citizens, and a large number of these individuals, of Black or Hispanic origin, will have what has been termed “ethnic hair.” It is necessary that both dermatologists and other treating physicians be able to approach these patients’ concerns from both a standpoint of knowledge and cultural competency. Residency training programs should take a lead in this pursuit, especially as they produce the next generation of dermatologists, the experts in hair and skin disease.

Excessive hair loss will likely affect a majority of African American women at one time or another. Hair loss and the consequential difficulties in hair styling may cause significant frustration among African American women and also have an impact on self esteem. Even as African American women suffer the highest incidence of overweight and obesity in our nation, they cite hairstyling and hair care concerns as a significant impediment to physical activity, with nearly half reporting avoiding exercise for fear of interfering with a hairstyle. This is concerning, considering the significant economic burden of obesity and obesity-related disease. Natural hairstyles, now gaining in popularity, have been offered as a possible solution to this hair-exercise quandary experienced by many African American women; however, unfamiliarity with natural hair styling techniques may be a barrier to the adoption of natural hairstyling by some women. Finally, there is significant dissatisfaction in patient encounters with physicians when discussing hair and scalp concerns. It is imperative that dermatologists, as well as other physicians, be adequately trained in not only the unique structure and behavior of African American hair, but also, the unique cultural practices and beliefs among African American women in relation to their hair.

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