Health Educ Behav OnlineFirst, published on April 13, 2007 as doi:10.1177/1090198106295531
Beauty Salons: A Promising Health Promotion
Setting for Reaching and Promoting Health
Among African American Women
Laura A. Linnan, ScD, CHES
Yvonne Owens Ferguson, PhD, MPH
African American women suffer disproportionately from a wide range of health disparities. This article
clarifies how beauty salons can be mobilized at all levels of the social-ecological framework to address disparities in health among African American women. The North Carolina BEAUTY and Health Project is a randomized, controlled intervention trial that takes into account the unique and multilevel features of the beauty
salon setting with interventions that address owners, customers, stylists; interactions between customers and
stylists; and the salon environment. The authors make explicit the role of the political economy of health theoretical perspective for understanding important factors (social, political, historical, and economic) that
should be considered if the goal is to create successful, beauty-salon-based interventions. Despite some
important challenges, the authors contend that beauty salons represent a promising setting for maximizing
reach, reinforcement, and the impact of public health interventions aimed at addressing health disparities
among African American women.
Keywords: beauty salons; cancer prevention; disparities in health; African American women; settings
Settings are recognized as a key influence on health and well-being (Mullen et al.,
1995; Poland, Green, & Rootman, 2000). In 1986, the Ottawa Charter for Health
Promotion stated, “Health is created and lived by people within the settings of their
everyday life; where they learn, work, play and love” (World Health Organization [WHO],
1986, p. 3). Although researchers often use more “traditional” health promotion settings, such as schools, churches, and work sites to promote health (Ammerman et al.,
Laura A. Linnan and Yvonne Owens Ferguson, Department of Health Behavior and Health Education,
School of Public Health, University of North Carolina, Chapel Hill.
Address correspondence to Laura A. Linnan, Department of Health Behavior and Health Education,
School of Public Health, University of North Carolina, Chapel Hill, Chapel Hill, NC 27599-7440; e-mail:
linnan@email.unc.edu.
The authors would like to thank Yvonne Wasilewski, PhD, MPH, for her contributions to the North
Carolina BEAUTY and Health Pilot Project; to Veronica Carlisle, MPH; Kacey Hansen, MPH and the entire
BEAUTY research team for their tireless efforts on the ongoing North Carolina BEAUTY and Health Project
study funded by the American Cancer Society (Grant TURSG-02-190-01-PBP). The authors also extend
gratitude to Morris Boswell, Joyce Thomas, Donna Hooker and Sharon Martin for their ongoing wisdom and
support as original members of the BEAUTY Advisory Board and for all the current members of the Board,
who have educated us about the beauty industry and have made this work possible.
Health Education & Behavior, Vol. X (X): xx-xx (Month XXXX)
DOI: 10.1177/1090198106295531
© XXXX by SOPHE
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Copyright 2007 by Society for Public Health Education.
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Health Education & Behavior (Month XXXX)
2002; Baskin, Resnicow, & Campbell, 2001; Markens, Fox, Taub, & Gilbert, 2002;
Mullen et al., 1995), low participation of African Americans in health promotion activities contributes to the health disparities that persist (Corbie-Smith, Thomas, Williams,
& Moody-Ayers, 1999; Crawley, 2000; Shavers, Lynch, & Burmeister, 2002). Here, we
explore the potential of beauty salons as an alternative, innovative, and “unconventional” setting in which to reach defined populations, especially African American
women, to participate in health promotion activities (Ferdinand, 1997; Forte, 1995;
Howze, Broyden, & Impara, 1992; Lewis, Shain, Quinn, Turner, & Moore, 2002;
Solomon et al., 2004). For the purposes of this article, we refer to health promotion
“activities” broadly and include opportunities to participate in health promotion
research and health education programs or services.
African American women, compared to Caucasian women, are disproportionately
affected by heart disease, cancer, and stroke, the leading causes of death among women
in the United States (National Center for Health Statistics, 2003). Thus, engaging
African American women in health promotion activities is an important step toward
addressing the health disparities that exist. African American women provide important
information and support to a wide circle of family members and friends on a range of
issues (Littlejohn-Blake & Darling 1993), including health, so that their participation in
health promotion activities not only helps sustain family solidarity but also improves
the health status of their family and their community.
A number of initiatives to promote health have been undertaken within beauty salons
(Ferdinand, 1997; Forte, 1995; Howze et al., 1992; Lewis et al., 2002; Linnan, Kim,
et al., 2001; Sadler, Thomas, Dhanjal, Gebrekristos, & Wright, 1998) yet very little theorybased research has been conducted (Linnan, Kim, et al., 2001; Sadler et al., 1998; Sadler,
Thomas, Gebrekristos, Dhanjal, & Mugo, 2000). This article will (a) briefly review the
literature on beauty salons as a setting for reaching and promoting health; (b) investigate
the historical, economic, political, and social context of beauty salons as a means of
reaching and promoting health among African American women; and (c) use The North
Carolina BEAUTY and Health Project to illustrate how to develop a theory-based, multilevel intervention effort to promote health among African American women who attend
beauty salons. Implications of this work for research and practice efforts will be
addressed, including specific challenges and opportunities for designing, implementing,
and evaluating salon-based interventions for African American women.
BEAUTY SALONS AS SETTINGS FOR PROMOTING HEALTH
The National Institutes of Health (NIH, 1994) Revitalization Act of 1993 has
increased minority participation in health promotion research, yet African Americans
continue to be underrepresented in many studies (Corbie-Smith et al., 1999; CorbieSmith, Thomas, & St. George, 2002; Crawley, 2000). One identified barrier to African
American participation is a lack of trust with the medical community (Corbie-Smith
et al., 1999; Corbie-Smith et al., 2002; Shavers et al., 2002). To overcome this barrier,
researchers proposing health promotion studies have gained access to this population
by collaborating with African American churches (Ammerman et al., 2002; Baskin
et al., 2001; Campbell et al., 1999; Derose et al., 2000; Lincoln & Mamiya, 1990; Reed,
Foley, Hatch, & Mutran, 2003).
Similar to churches, beauty salons are unique and important institutions within the
African American community (Willett, 2000). First, beauty salons are located in all
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Linnan, Ferguson / Beauty Salons & African American Women
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communities, regardless of size, geographic location, or rural/urban status. In the
United States, there are 312,959 licensed beauty-centered salons, and owners report
serving an average of 155 clients per week (Rudner, 2003). Second, salons are places
that women frequent regularly—from weekly visits to at least once every 4 to 8 weeks.
Third, women spend a lot of time in the salon during a typical visit—from 45 minutes
to 5 hours, depending on the services received. Fourth, salons are places where health
is a typical topic of conversation. Solomon and colleagues (2004) observed 10 salons
and found that approximately 18% of the talk that occurs in a salon is health related.
Ninety-four percent of licensed cosmetologists report talking about health with their
customers (Linnan, Kim, et al., 2001). More than 20 years ago, the tobacco industry
also recognized the beauty salon as an important setting for reaching African American
women. In an effort to increase the market share of Virginia Slims cigarettes among
African American women smokers, Philip Morris U.S.A. planned to use cosmetologists
to promote their cigarette brand with their “Virginia Slims Beauty Salon Program,”
whereby they offered discounts on beauty services for salon customers (Kathryn
Alexander Enterprises, Inc., 1988). According to this report, the economic incentive for
promoting Virginia Slims piqued the interest of African American beauty salon owners
and operators, but they did not want to encourage their clients to smoke cigarettes.
Black salon owners/managers were often excited by the possibility of earning additional
income derived from the optional sale of consumer goods. However, they were generally
not interested in selling cigarettes on the premises or encouraging smoking in the environment. (Kathryn Alexander Enterprises, Inc., 1988, p. S-4)
It is clear that the beauty salon represents a place that is accessible in all communities and frequented by African American women on a regular basis. As a result, this setting offers important opportunities for both reach and reinforcement of health
messages. However, the beauty salon is more than a great “place” for promoting
health—it also holds great promise because of the unique personal relationship that
exists between the cosmetologist and the customer. Customers and cosmetologists talk
to each other regularly, including talk about all kinds of health topics such as nutrition
and physical activity (Linnan, Kim, et al., 2001; Solomon et al., 2004). Furthermore,
these health issues are discussed naturally in the beauty salon setting—often in
unplanned and unexpected ways—and initiated equally by the cosmetologist and the
customer (Solomon et al., 2004). Women know that the bond between a cosmetologist
and her customer is a unique blend of loyalty, trust, support, and comfort.
To further understand the unique relationship between cosmetologists and their customers, Cowen and colleagues (Cowen, Gesten, Boike, Norton, & Wilson, 1979) conducted structured interviews with 90 cosmetologists and characterized them as informal
caregivers who were perceived by customers as competent, trustworthy, and likeable.
Wiesenfeld and Weis (1979) conducted a successful 10-week group mental-health training
program focused on interpersonal relations for cosmetologists to mobilize their expertise
as “natural helpers” by increasing their use of helping strategies. Licensed cosmetologists
have been successfully trained to deliver messages to their customers about getting a regular mammogram (Howze et al., 1992; Sadler et al., 1998; Sadler et al., 2000). More
recently, using a community-based participatory research approach, Linnan, Ferguson, and
colleagues (2005) gave a 4-hour training workshop for licensed stylists in two salons who
were willing to deliver selected health messages to their customers. Twelve months later,
customers reported changing the selected health behaviors based on conversations with
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Health Education & Behavior (Month XXXX)
their cosmetologist; and the more they reported talking with their stylist, the more likely
they were to report behavioral changes (Linnan, Ferguson, et al., 2005). In addition, the
trained cosmetologists reported that they continued to deliver health messages beyond the
8-week intervention period (Linnan, Ferguson, et al., 2005).
Several additional projects have used beauty salons as a setting for implementing
health promotion programs or have capitalized on the unique relationship between
licensed cosmetologists and their customers. Ferdinand (1997) conducted hypertension
screening and education programs within beauty salons. Several researchers (GreenBishop, 1996; Lewis et al., 2002) have promoted condom use and HIV/STD prevention
programs in both beauty salons and barbershops. Madigan, Dombrouski, Krein, and
Klamerus (2000) conducted a community health educational campaign on cardiovascular
disease prevention, hypertension screening, and kidney health delivered to community
residents by licensed cosmetologists.
It also appears possible to make changes in the salon environment to support health.
For example, Linnan, Emmons, and Abrams (2002) delivered The Smokefree Shop
Initiative to interested beauty salons in the state of Rhode Island. A Community
Advisory Board guided all aspects of the intervention plan and delivery. After completing a brief survey to assess their current smoking-policy status, responding salons
received an intervention that was matched to their interest level in creating a more
restrictive smoking policy. Results indicated that 22% of high-readiness salons (versus
12% of low-readiness salons) were successful in adopting a total smoking ban at 12
months postintervention (Linnan et al., 2002).
This brief literature review points out that utilizing the beauty salon as a setting for
reaching African American women with health programming is both feasible and desirable, not only because it is a place that is readily accessible and frequently visited by African
Americans, but also because of the social environment and strong bond between cosmetologists and their customers. Although researchers have used this bond to promote health
among salon customers, these efforts have not typically been theory driven and have only
been evaluated on a limited basis in terms of impact on customer or stylist health.
A Theory-Linked Perspective for Working in
Beauty Salons to Promote Health
Beauty salons represent a place where it appears to be feasible to reach African
American women and promote health, yet there are few theory-linked explanations for
working in partnership with these settings. The social ecological framework (SEF) is
a useful heuristic that posits that individual health behavior is influenced at multiple
levels: intrapersonal, interpersonal, organizational, community, and policy (McLeroy,
Bibeau, Steckler, & Glanz, 1988; Stokols, 1992). To understand the beauty-salon-based
research literature in this context, we categorized the current literature according to
these five levels of the SEF (see Table 1). Several studies could be categorized at each
level of the SEF, except that very few beauty-salon-based research studies are at the
“higher” levels of the SEF (e.g., those at the policy- or community-levels; see Table 1).
Thus, although existing literature helps address factors at the intrapersonal, interpersonal, and organizational levels, there appears to be a gap in understanding how to best
understand and intervene at the macro levels of the SEF. To address this gap, we introduce the political economy of health (PEH) as a macro-level theoretical perspective that
may provide additional insight and understanding of the full range of intervention possibilities within beauty salons so as to maximize intervention effectiveness.
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Table 1. Selected Findings and Descriptions of Current Beauty-Salon-Based Research
Focusing on African American Women by Level of Social-Ecological Framework
Level
Intrapersonal
Interpersonal
Organizational
Community
Policy
Selected Findings and Related References
• Evaluation of the knowledge, attitudes, and behaviors of clients who
received breast cancer awareness messages from trained
cosmetologists (Howze, Broyden, & Impara, 1992; Sadler, Thomas,
Gebrekristos, Dhanjal, & Mugo, 2000)
• Survey of stylists’ knowledge, attitudes, and motivations for promoting
health messages to their customers (Linnan, Kim, et al., 2001)
• Evaluation of the feasibility and impact of training African American
cosmetologists to deliver health promotion messages to their clients
(Green-Bishop, 1996; Howze et al., 1992; Sadler, Thomas, Dhanjal,
Gebrekristos, & Wright, 1998; Sadler et al., 2000)
• Observational study of five African American and five Caucasian
beauty salons in North Carolina to gain insight on the types and
topics of conversations between cosmetologists and their customers
(Solomon et al., 2004)
• Results that demonstrate customers who talk more often with their
trained cosmetologist about health also reported more changes in
health behaviors (Linnan, Ferguson, et al., 2005)
• Considered the salon physical and social environment to design
health interventions that influence beauty salon as a small business
organization (Linnan et al., 2006; Solomon et al., 2004)
• Designed and evaluated a successful tailored intervention to
influence beauty salon owners to adopt a restrictive smoking policy
in their beauty salons (Linnan, Emmons, & Abrams, 2002)
• Conducted a community needs assessment of African American
barbers and cosmetologists for a STD/HIV peer educator program
recognizing the community values, assets, and norms (Lewis, Shain,
Quinn, Turner, & Moore, 2002)
• Used African American barbershops and beauty salons as blood pressure
screening and information sites for customers (Ferdinand, 1997)
• No published literature available
As illustrated in the Ottawa Charter for Health Promotion (WHO, 1986), key characteristics of a settings-based approach are its social, cultural, and environmental influences on health (Green, Poland, & Rootman, 2000; Mullen et al., 1995; Whitelaw et al.,
2001). Fitzpatrick and La Gory (2000) write in Unhealthy Places that Barker (1967)
defined place as “behavior settings” that are bounded in space and time within a structure and are interrelated with physical, social, and cultural properties in a way such that
certain patterns of behavior are likely to be displayed. Understanding this dynamic
interaction is important when using a settings-based approach because it recognizes the
social and structural locatedness and embeddedness of the setting (Fitzpatrick &
La Gory, 2000). However, Green et al. (2000) have argued that this ecological perspective may neglect the historical and political context critically important to successful
settings-based health promotion research and practice. Therefore, PEH is a theoretical
perspective that may be particularly useful in bridging this gap. Specifically, the PEH
perspective is not a single theory but a broad theoretical framework that emphasizes
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Health Education & Behavior (Month XXXX)
how history, the economy, policy, and society affects the lives, experiences, health
status, and life chances of individuals and groups (Alford & Friedland, 1985; Minkler,
Wallace, & McDonald, 1995). As a theoretical perspective, PEH offers a critical lens
that allows one to fully explore the beauty salon as a historical, economic, political, and
social context for understanding how to best reach and address disparities in health
among African American women. Linnan, Sorensen, Colditz, Klar, and Emmons (2001)
have used the PEH perspective to understand low participation among employees in
work site health promotion programs. Similarly, if the beauty salon represents a promising setting for reaching African American women, and low participation of African
American women in health promotion research and programs is a barrier to addressing
disparities in health, then which salon-based historical, economic, political, and social
factors should be considered as a means of overcoming these barriers to participation?
Here, we offer an example of one multilevel, salon-based intervention study—The
North Carolina BEAUTY and Health Project—that applied a community-based participatory research process and a PEH theoretical perspective with an aim toward addressing disparities in health among African American women. Here, we review the
historical, economic, political, and social realities of the beauty salon that informed our
intervention development.
History. Historically, beauty salons have served as a setting for social interaction,
political activism, and community organizing as well as providing an avenue for economic mobility in the African American community (Willett, 2000). Because of racial
segregation, discrimination, and other social, political, and economic forces, opportunities for employment were limited for African American women in the late 1800s and
early 1900s (Willett, 2000). Most hairdressing services among African Americans took
place in homes rather than in formal beauty salons. As social and economic opportunities improved for African American women, beauty salons became an opportunity for
employment and for business entrepreneurship. Operating a beauty salon was one of the
earliest, most respected, and most profitable professions that African American women
pursued (Willett, 2000).
In the early 20th century, entrepreneurs Annie Turnbo Malone and Madam C. J.
Walker capitalized on the existing structure of African American beauty salons to promote
their hair care products while providing economic opportunities, social support, and community organizing activities for women (Bundles, 1990; Willett, 2000). With their goal of
improving the status of African Americans economically, socially, and politically, these
women set the standards and laid the foundation for the 21st-century African American
beauty salon. Born in 1869 and orphaned as a child, Annie Turnbo Malone lived with her
older siblings in Metropolis, Illinois (Bundles, 1990). In the 1890s, she began experimenting with preparations to help African American women like herself care for their hair
and scalp. She developed a popular hair product called Poro, a Mende (West African) term
for a “devotional society” (Bundles, 1990). Madam C. J. Walker had a similar background as Annie Turnbo Malone in that she was orphaned at a young age and lived with
her sister (Bundles, 1990). Madam C. J. Walker is best known for being one of the first
women in the United States to become a self-made millionaire (Bundles, 1990). Madam
C.J. Walker is also known for the Walker system, the “shampoo-press-and-curl” method
of straightening hair that was to become the foundation of the Black beautician industry
(Byrd & Tharps, 2001). Through their entrepreneurial efforts, Annie Turbo Malone and
Madam C. J. Walker hold a prominent place in African American history and serve as
important role models for African American women today.
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Economics. Economically, the beauty salon was recognized as an important institution
because it was one of the few independently owned, African American businesses within
the community (Willett, 2000). As Walker and Malone continued to emphasize women’s
empowerment, business ownership, and demonstrated success in the business world, the
number of beauty salons catering exclusively to African American clients increased
rapidly in the United States (Willett, 2000). For example, the 1920 U.S. Census reported
that 12,660 African American women were working as “female barbers and hairdressers”
(Willett, 2000). Furthermore, by the 1930s, the president of the National Beauty Culturists
Association, Rosilyn Stewart, reported that African American beauty salons employed
150,000 women and were located in 72 cities and 34 states (Willett, 2000). In New York,
the State Department of Labor found that in general, African American women “spoke
enthusiastically of beauty parlor work as a new opening for Negro women and a field
which offers opportunities for better wages and more independence than most work available for them” (Willett, 2000). At present, beauty-centered salons in the United States
employ approximately 1,123,151 licensed cosmetologists (Rudner, 2003). The number of
beauty salons and cosmetologists increase every year (U.S. Department of Labor, 2004),
so there continues to be opportunity for career and economic advancement in this field for
women generally, and African American women in particular.
Political. Beauty industry innovators Annie Turbo Malone and Madam C. J. Walker
sparked a spirit of political activism during the late 1800s to early 1900s (Willett, 2000).
Beauty salons and cosmetologists catering to African American women held a prominent
role as civil rights advocates and community leaders (Peiss, 1998; Willett, 2000). This
prominence continued during the 1960s Civil Rights Movement when beauty salons were
actively used as “safe” meeting places to communicate and politically organize the
African American community (Willett, 2000). Civil rights activists recognized that
because the beauty salon was independently owned and operated by African Americans
and less visible to Whites than African American churches, it was an ideal meeting place
for organizing the community (Willett, 2000). Thus, beauty salons have played an instrumental role in political activism and community organizing over time. Local beauty
salons continue to be places where political elections are discussed, along with other current events that influence the lives of women who frequent these locations.
Social. Throughout the 20th century, African American women looked toward cosmetologists as reliable and trusted resources of information. The cosmetologists’ active
role in the community allowed them to have a more intimate relationship with their customers that extended beyond the beauty salon setting (Willett, 2000). This intimate relationship also allowed customers and cosmetologists to share stories about their family,
relationships, and jobs (Solomon et al., 2004). Willet (2000) has described the beauty
salon as a place where women transcend daily life and seek support in coping with psychological, social, cultural, and economic stressors. Within the African American community, beauty salons have a unique oral cultural tradition in which the exchange of
family histories and information remains an important preservation of culture and social
interaction (Forte, 1995). This oral exchange sometimes occurs in the form of “cross
talk,” or group conversations between cosmetologists and their customers, another unique
social and cultural feature within many African American beauty salons (Solomon et al.,
2004). Thus, beauty salons represent a safe, resourceful, culturally appropriate, and empowering setting that allows for the natural exchange of goods, services, and information in
the lives of African American women.
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Health Education & Behavior (Month XXXX)
The PEH perspective helps us understand these important historical, economic,
political, and social elements of African American beauty salons so we can develop
strategies that will increase the participation of African American women in health promotion programs/activities and research offered in these settings. Minkler et al. (1995)
suggested that health behavior researchers and practitioners use the PEH perspective to
complement extant micro-level theories used in the field. Next, we describe the North
Carolina BEAUTY and Health Project where we used the PEH macro-level perspective,
micro-level theories of social cognitive theory, and transtheoretical model (GreenBishop, 1996) and were grounded in community-based participatory research approach
(Israel, Schulz, Parker, & Becker, 1998; Linnan et al., 2006; U.S. Department of Labor,
2004) while intervening to address disparities in cancer risk among African American
women who attend beauty salons. More completely understanding the important role
that beauty salons hold from a historical, economic, political, and social context helped
us consider the underlying power that this setting may hold for promoting health among
African American women.
THE NORTH CAROLINA BEAUTY AND HEALTH PROJECT
The North Carolina BEAUTY and Health Project (referred to hereafter as the
BEAUTY Project) began as an idea about promoting health in beauty salons that was
shared with one North Carolina community. BEAUTY is an acronym for “Bringing
Education and Understanding to You,” which represents the role of the licensed cosmetologist as a natural helper and educator in this intervention. This idea was discussed,
accepted, guided, and brought to reality in cooperation with community partners at all
stages of its development over time.
We first established a BEAUTY Advisory Board by recruiting salon owners, cosmetologists, customers, beauty product distributors, and local health educators to explore
the feasibility of developing the idea for a health promotion intervention in beauty
salons in one primarily rural North Carolina county (Green-Bishop, 1996). True community partnerships create a shared vision and commitment, so the BEAUTY Advisory
Board helped explore whether beauty salons owners and stylists in one county might be
interested in getting involved with health promotion activities. No assumptions were
made about the fact that this would work or about the type of health promotion messages that might be delivered. The advisory board guided the research team at all steps
of the planning process, including the development of a survey distributed to all
licensed cosmetologists in the county and analysis/interpretation of the results. This
community-based approach allowed for true collaboration between researchers and
community members, building relationships and building trust, while lessening the tension sometimes present in typical university-community research partnerships (Linnan
et al., 2006). Results of the cosmetologist survey are described elsewhere (Linnan, Kim,
et al., 2001), but briefly, 85% of local stylists completed the survey and were highly
enthusiastic about participating in a project to promote health among their customers.
Although researchers should be cognizant of the potential stigma associated with some
health promotion topics (e.g., HIV/AIDS, breast cancer, smoking; Green-Bishop, 1996)
when recruiting African American beauty salons and their stylists to participate in
health promotion research, we did not encounter any such problems in the BEAUTY
Project because we specifically began our work by addressing health issues that stylists
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told us they were comfortable with and interested in discussing (e.g., diet and physical
activity; Linnan, Kim, et al., 2001).
After reviewing results of the stylist survey, the BEAUTY Advisory Board supported
the idea of testing an intervention to promote physical activity and increasing fruit and
vegetable intake in two local salons. With their guidance, we developed an intervention
that consisted of an interactive, educational display for the salon that would cue both the
customer and cosmetologist to talk about key health messages and a training workshop
for interested cosmetologists on how to promote health messages during a typical salon
appointment. The BEAUTY Advisory Board reviewed all training materials and the educational display before it was implemented in the two salons. Once the training was completed and the displays set up, we monitored customer self-reported health changes and
interviewed participating stylists. Results demonstrated feasibility in delivering the stylist training and salon-based intervention, enthusiasm from stylists/customers, and, positive self-reported behavior changes among customers immediately postintervention
(8 weeks) and in a 12-month follow-up (Linnan, Ferguson, et al., 2005).
Recognizing that beauty salons are not only a cornerstone of the community but also
a place of business, we worked with salon owners to devise an intervention strategy that
would benefit the salon business while addressing the research goals of the BEAUTY
Project. We solicited media attention from local newspapers and television programs that
profiled the pilot study and the participating salons. This provided free publicity for the
salons and also aided us in our recruitment efforts. Because our aim for the pilot study
was to see whether it was feasible to work in partnership with licensed cosmetologists
as natural helpers to promote health messages, we held the stylist-training workshop on
a Monday, the day when beauty salons are typically closed, and we compensated the cosmetologists for their participation in these trainings. Using the experiences and advice
of the BEAUTY Advisory Board members we incorporated the realities into our intervention plan and helped to ensure that beauty salon owners and licensed cosmetologists
were able to participate if interested, without fear of economic loss. In fact, we discussed
ways that the salon owners could position the BEAUTY Project as a competitive advantage for their business and provided banners for window promotions to acknowledge
their participation in the project as a means of recognition for their community service.
Politically, we found that our salon owners and cosmetologists were concerned about
the sustainability of the program after the pilot study was complete. In our pilot study,
we found that some cosmetologists reported that they continued to promote the cancerprevention messages 12 months after the pilot study ended (Linnan, Ferguson, et al.,
2005). The BEAUTY Advisory Board members identified possible funding sources and
wrote letters of support for grant proposals written to extend testing of these ideas
beyond the initial pilot test. When additional funding for a larger randomized trial was
received, we added some new members to the BEAUTY Advisory Board but maintained a core group of enthusiastic partners from the original board who have served as
true ambassadors for the project for more than 7 years at this point. Board members
helped to develop a recruitment video that was a featured component of the recruitment
effort undertaken to identify 40 new salons that were interested in participating in the
larger study. Recruitment results revealed that board members’ referrals were the
recruitment strategy most likely to yield successful sign-ups to participate in the study
(versus mail, phone calls, or drop-in visits; Linnan, Carlisle, et al., 2005).
Understanding the social environment of the beauty salon was also important during our
intervention development process. In addition to the survey of licensed cosmetologists,
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Health Education & Behavior (Month XXXX)
we also conducted an observational study within 10 beauty salons to assist with intervention development (Solomon et al., 2004). We wanted to understand more fully the
type of interactions that took place in salons, how much health talk occurred, what type
of health talk occurred, and who initiated the conversation and to explore how the physical environment might be used to support healthy changes (Solomon et al., 2004).
These findings provided us with insight on the important natural-helper role that cosmetologists play in providing informational, emotional, and social support to their customers (Solomon et al., 2004), which led to the development of the cosmetologist-training
workshop, the specific role-play activities that were included, and the development of
the educational display that provided cues for customers as well as cosmetologists to
initiate conversations about health (Linnan, Ferguson, et al., 2005; Solomon et al.,
2004). Combined with the PEH perspective and the participatory planning process that
took place with the BEAUTY Advisory Board, the observational study gathered additional important insights about similarities and differences that exist by race/ethnicity
of customers in the salons and how to mobilize the salon environment to support health,
which proved useful during the development of the pilot intervention. Results indicate
that the salon environment has the potential to reinforce health messages over time and
to create healthy norms that can be reinforced within the salon setting and disseminated
beyond the salon into the larger community. These are just a few examples of how the
BEAUTY Advisory Board has guided intervention development and kept it firmly
rooted in the historical, economic, political, and social realities of the beauty salon.
CONCLUSION
Beauty salons are a promising setting for promoting health, but they also present
unique challenges to those planning, delivering, and evaluating health promotion activities. If not part of a franchise, most salons are single-owned (or jointly owned) small
businesses. Small businesses are vulnerable to all types of economic hardship. Even
when the small business has a strong customer base, a cosmetologist within one salon
may decide to change locations. When a cosmetologist moves, her customers typically
move as well, which creates both intervention and research challenges. Practically
speaking, we have also learned that salons are extremely busy on certain days of the
week (typically, Thursdays through Saturdays), less busy on Tuesdays and Wednesdays,
and often closed on Sundays and/or Mondays. Again, in nonfranchise salons, one must
consider matching interventions strategies to the ebb and flow of a busy work environment. Some intervention strategies (e.g., health magazines or educational displays) may
be delivered without much worry about the busy-ness of the environment. However, if
one is interested in having cosmetologists attend training workshops, or deliver health
messages, one must consider appropriate training days (e.g., Mondays when they are
not working), and to be realistic about when the messages could be “delivered” to customers (e.g., slow days versus busy). We also learned to avoid putting demands on stylists or salons 3 to 4 days immediately prior to a major holiday such as Easter or
Mother’s Day when most salons are extremely busy.
Conducting research within beauty salons offers challenges because filling out
paperwork is not something that typically happens in a beauty salon. Cosmetologists may
be unwilling to record their message-delivery efforts; and customers may be unwilling to
complete surveys. Interventions cannot be easily delivered to participants at the same
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Linnan, Ferguson / Beauty Salons & African American Women
11
time because customers have different appointment schedules (e.g., weekly, monthly, etc.)
and request different hair-care services. African American women with a simpler hairstyle (e.g., simple cut/style) may be in the salon for just 1 to 2 hours compared to
women with more complicated hairstyles that require relaxers or braiding that may
demand 2 to 4 hours of salon time. The number of visits required for certain hair-care
services and the amount of time per visit must be taken into account when determining
the “dose” of intervention that a particular customer may receive for research purposes.
When women face economic hardships (e.g., rising gas prices or food prices), they
tend to get their hair done less often. Thus, extreme changes in the larger economic and
social context are likely to influence intervention opportunities and successes.
However, our data suggest that more than 80% of African American women who visit
a salon frequent the salon at least once every 6 weeks, whereas 17% visit weekly
(Linnan et al., 2006). And, although our data from African American salon participants
reflects income diversity (Linnan et al., 2006), it is plausible to expect that low-income
women are less likely to visit the beauty salon at all (or far less) than moderate- or
higher-income women. The fact that not every African American woman frequents a
beauty salon is a limitation of promoting health in this setting as well. We need additional data to determine whether African American women who visit salons are representative of the larger population of African American women and to understand the
differences (and/or similarities) that may exist.
Despite these practice- and research-based challenges and opportunities, we remain
convinced that beauty salons represent a promising place for promoting health, particularly among African American women. It is a promise unfulfilled unless theory-driven
interventions at both micro and macro levels of the SEF that use participatory approaches
to engage the salon owners, cosmetologists, customers, and community health professionals are developed and rigorously evaluated.
Implications for Practice
A “one-size-fits-all” approach when conducting settings-based health promotion
activities or research with beauty salons should be avoided (Poland et al., 2000;
Whitelaw et al., 2001). There is much diversity among African American beauty salons,
including various geographical locations, sizes, costs, customers, philosophies, and
services offered, which health promotion researchers must recognize. Although beauty
salons within the African American community share the same historical, economic,
political, and social foundations, one salon owner may have very different interests and
motivations about getting involved in health promoting activities. Although they often
share a common history and represent an important community setting, we recognize
that each beauty salon is unique.
The North Carolina BEAUTY and Health Project represents one example of how a
multilevel intervention can be guided by a participatory planning process and a PEH
perspective that takes into account the historical, economical, political, and social realities of the beauty salon setting serving African American women. Understanding these
important realities not only led to a successful implementation of the intervention pilot
study (Linnan, Ferguson, et al., 2005) but also has guided our successful recruitment of
40 new beauty salons and more than 1,100 African American women who frequent these
salons as customers into a large, randomized-controlled intervention trial presently
under way (Linnan et al., 2006). Like all settings, beauty salons bring both opportunities
and challenges for those who intend to conduct research or provide programs and/or
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12
Health Education & Behavior (Month XXXX)
services. We hope that others consider developing and rigorously testing salon-based
interventions to build the evidence base and to work toward eliminating persistent disparities in health among African American women.
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