Abstract
Introduction: African American (AA) women have reported hair maintenance as a barrier to regular exercise; however, to our knowledge, this study is the first to identify primary care provider thoughts, attitudes, beliefs, and knowledge regarding hair as a barrier to increased physical activity among AA females.
Methods: A 13-question electronic survey was sent via email to 151 clinicians working within a department of family medicine's 8 ambulatory clinics within a large urban academic medical center.
Results: A total of 62 primary care clinicians completed the survey, which is a response rate of 41%. The vast majority of respondents (95%) sometimes/often engage in discussions with AA female patients regarding physical activity. However, 76% of respondents have never included a hairstyling or maintenance assessment in that discussion and only 34% noted being comfortable discussing this topic. Among a list of potential barriers to exercise, hair maintenance/scalp perspiration was rarely endorsed as important by clinicians.
Discussion: This study highlights a need for increased education among primary care providers regarding AA hair care and maintenance practices as a barrier to increased physical activity in AA women. If specific barriers to increasing healthy habits among AA women are to be addressed, there must be a baseline knowledge of hair care and maintenance barriers, an understanding of the strong influence of cultural norms and practices as it relates to physical activity and exercise, and an increased comfortability when engaging in difficult cross-cultural conversations to ultimately improve health outcomes in AA females.
- Cultural Competency
- Exercise
- Habits
- Hair
- Health Behavior
- Life Style
- Minority Health
- Obesity
- Patient-Centered Care
- Primary Health Care
- Social Determinants of Health
- Surveys and Questionnaires
African American (AA) women have the highest prevalence of obesity and obesity-related conditions, including type 2 diabetes, hypertension, heart disease, and stroke.1 Relatedly, this group is less likely than other ethnic groups to participate in physical activity or exercise.2,3 A small body of research has identified what AA women perceive to be barriers to increasing and sustaining regular exercise in their lives: cost, time, and hair maintenance.4⇓⇓–7 Regarding hair maintenance, in two different surveys of nonexercising AA women, respondents reported “sweating out my hairstyle” as a barrier to exercise.4,8 This barrier is related to the time and money required to restyle hair after perspiration. In addition, when AA women seek out help for hair-related issues, a significant number are dissatisfied with hair-related encounters with physicians because AA women did not feel as though their provider understood AA hair.9
A 2013 study proposed that physicians would do well to suggest hairstyles for AA women that would be conducive to increasing physical activity.8 In August 2011, then US Surgeon General Regina Benjamin, an AA woman, called attention to the problem, “Oftentimes you get women saying, ‘I cannot exercise today because I do not want to sweat my hair back or get my hair wet’”.10 Researchers have noted that there should be a strategic focus placed on identifying patients who find hair maintenance a barrier to exercise.6 However, although concerns about hair maintenance could be a potential point of intervention when primary care providers promote exercise to their AA female patients, to our knowledge there are no studies that consider primary care provider perceptions of the management and maintenance of AA female hair. The purpose of this study was to address this gap by identifying primary care provider thoughts, attitudes, beliefs, and knowledge regarding the maintenance of AA female hair as a barrier to increased physical activity.
Methods
The study setting was a department of family medicine with 8 ambulatory clinics within a large Midwestern academic medical center (AMC). A recruitment e-mail was sent to the department clinician e-mail listserv (151 unique e-mail addresses) that included a link to the survey instrument. The survey elicited clinician thoughts, attitudes, beliefs, and knowledge as it relates to AA hair maintenance and physical activity via Likert, multiple choice, and yes/no questions (see Table 1 for survey questions and answer categories). The final question was open-ended. This study protocol was approved by the institutional review board affiliated with the AMC.
Responses to a Survey of Primary Care Provider Perceptions of Hair Care Maintenance as a Barrier to Increased Physical Activity in African American Women
Results
A total of 62 clinicians completed the survey (41% response rate). Table 1 presents respondent demographics and a distribution of answers to survey questions. Respondents were identified as nurse practitioners, physician's assistants, and family medicine residents and attendings. There was ethnic diversity among respondents, with 30% identifying as nonwhite. A total of 95% of respondents often/sometimes engage in discussions with AA females regarding physical activity; however, 76% of respondents have never included hairstyling or maintenance assessment in that discussion. From a predetermined list of barriers to increased physical activity, the most frequently selected factors included location/accessibility of a gym, mood/mental health, and transportation. The least frequently selected barriers to increased physical activity included scalp perspiration and cost of hair maintenance.
Nearly 60% of clinicians believed discussing hair maintenance strategies would be beneficial and possibly help to increase physical activity habits in AA female populations; however, only 34% of providers noted that they were comfortable or relatively comfortable discussing this topic. Fifty respondents answered the open-ended final question. The majority reported feeling uneducated, unaware, or unfamiliar. One respondent stated, “I know how important it is in the AA community and do not want to upset anyone.” Another respondent stated that they were not comfortable with this topic because of “previous episodes of asking about hair to AA females that have resulted in them being insulted.”
Discussion
Overall, the study results indicate clinicians place a value on the health and wellness of patients, and particularly AA female patients, when it comes to discussions of physical activity and exercise. However, the majority of clinicians in this study reported that they do not feel comfortable discussing haircare or hairstyle maintenance with their AA female patients, and furthermore, there was little knowledge of haircare practices as a potential barrier to exercise. The scope of medicine in modern day family practice is multicultural, cross-cultural, and personalized. The patient-clinician discussions regarding physical activity and barriers should reflect this reality. Our study supports the need to incorporate this cultural competency into continuing medical education opportunities and medical education curriculums.
This study is subject to the external validity threat of a small, single-site case study. In addition, the number of respondents was too small for statistical analysis of responses across physician demographic categories. However, the ethnic diversity of our physician sample and the patients they serve is a strength and supports the external validity of our findings. Given that these providers were not aware or comfortable with AA hair maintenance as a barrier to physical activity, it is reasonable to assume that the majority of primary care providers are not better informed. In addition, 80% of respondents answered the open-ended question. This is evidence of the interest and novelty of this topic and highlights the need for further study in this area.
The benefits of physician education on this topic are similar to other cultural competency training and could yield improvements in health care provider knowledge, attitudes, and skills and increased patient satisfaction.11,12 Furthermore, faculty modeling of cultural competency behavior to learners, that is, medical students and residents, will begin to address knowledge gaps and cultural chasms at an earlier academic level.13 Incorporating this knowledge during motivational interviewing will, in theory, begin to reveal barriers to exercise among AA patients and is an important step toward building trust and rapport with patients.
Future studies are needed to develop a continuing medical education curriculum on hair maintenance as a barrier to physical activity, which should be developed in consultation with members of the AA female community, and to test the efficacy of this curriculum. Subsequent studies regarding the efficacy of interventions such as low-maintenance hair styling practices and motivational interviewing may give insight to evidence-based strategies for helping AA females increase their physical activity.14,15 Provider education has the potential to improve the physician-patient relationship, which could have a lasting impact on the long-term health outcomes of AA females.
Acknowledgments
The authors would like to thank the providers who gave their time to respond to our survey and Dr. Faraz Ahmad for his early encouragement as an advisor.
Notes
This article was externally peer reviewed.
Funding: none.
Conflict of interest: none declared.
To see this article online, please go to: http://jabfm.org/content/32/6/944.full.
- Received for publication May 6, 2019.
- Revision received July 16, 2019.
- Accepted for publication July 18, 2019.
