Hair Care Practices as a Barrier to Physical Activity in African American Women

Objective To characterize the influence of hairstyle maintenance on exercise behavior in African American women.

Design A 40-item survey with questions concerning hair care practices, physical activity, and the relationship between the two.

Setting University-affiliated dermatology department at an academic medical center in Winston-Salem, North Carolina.

Participants A total of 123 African American women from 21 to 60 years of age were surveyed; 103 women completed the questionnaire.

Main Outcome Measures The statistical significance of relationships between hair care practices and physical activity was determined.

Results Fifty percent of African American women surveyed have modified their hairstyle to accommodate exercise and nearly 40% (37.9%) avoid exercise at times owing to hair-related issues. Respondents who exercised less owing to hair concerns were 2.9 times less likely to exercise more than 150 min/wk (95% CI, 0.9-9.4; P = .08).

Conclusion Dermatologists can discuss hair management strategies during exercise that facilitate routinely performing exercise.

Regular physical activity (PA) is associated with a decreased risk for obesity and obesity-related conditions.¹ Compared with other ethnic groups and men, African American women are the least likely to meet levels of PA mandated in 2007 by the Centers for Disease Control and Prevention and American College of Sports Medicine, with only 19.8% to 36.1% of African American women participating in recommended levels of PA.^1,2 In 2008, the US Department of Health and Human Services (USDHHS) released updated Physical Activity Guidelines for Americans to reflect evidence-based levels of PA shown to significantly reduce risk for premature death, coronary heart disease, stroke, hypertension, and type 2 diabetes mellitus in adults.^3-5 Sufficient PA was defined as moderate-intensity aerobic PA for at least 150 min/wk or vigorous-intensity aerobic PA for at least 75 min/wk. Muscle strengthening activities performed at least twice weekly were also recommended.^3-5

Barriers to PA and weight loss can be personal (lacking time, energy, motivation, or knowledge), social (caregiving responsibilities or lack of social support), financial (cost of participating in organized PA or cost of equipment), and environmental (concerns for personal safety or lack of nearby exercise facilities).^6,7 Dermatologic barriers are not as well explored in the literature. Many patients believe that exercise and associated sweating may exacerbate common dermatologic conditions, including acne,^8-14 atopic dermatitis,^15,16 and folliculitis.^14,17 An additional and minimally explored dermatologic barrier to exercise cited by African American women is hairstyle management.^6,18 Hair care and hairstyle maintenance in the African American female population can be a tedious and time-consuming process.^19-21 Given the often costly hairstyling practices and the relative infrequency of hair washing needed to maintain many common hairstyles in African American women, they may opt to avoid exercise and associated sweating, which would negate time and financial investments.¹⁸In a previous study,¹⁸ nearly half of African American women surveyed stated that hair care issues directly affected their exercise practices.

Thus, the objectives of this study were 2-fold: to determine the exercise level of our target population, African American women, and to further characterize the influence of dermatologic barriers, including hairstyle maintenance, on exercise behavior in African American women.

From October 1 through October 31, 2007, a questionnaire was randomly administered to women in a vestibule outside the waiting room of an academic dermatology department. Inclusion criteria included self-identified African American race, female sex, age between 21 and 60 years, and willingness and ability to read and complete the hair and exercise survey. No specific exclusion criteria were defined. A variety of patients, patient family members, and hospital staff members participated in the study. Patients were not required to list their reason for presenting for dermatologic evaluation. No incentive was provided for participation, and the study protocol was approved by the institutional review board at Wake Forest University School of Medicine. The survey was developed by the investigators from the dermatology department in Winston-Salem and the Gramercy Research Group. The 40-item questionnaire was completed by most women in 20 to 25 minutes. The survey has not been previously validated. The survey objectives were to define current PA level in the target population, explore the role of hair care satisfaction and maintenance, and characterize exercise behavior modification relating to hair care.

Physical activities of survey respondents were analyzed individually and condensed into 4 representative categories for analysis. The “aerobic/gym” category included running, biking, spinning, aerobics, kickboxing, weights, hiking, martial arts, elliptical, yoga, and pilates. The “sports” category included tennis, power walking, frisbee, basketball, golf, skating, volleyball, baseball, bowling, and soccer. “Water activities” included swimming/water exercise. The final category was “incidental activity,” which included gardening, dancing, walking, housework, and taking the stairs.

Survey respondents were asked to quantify the number of days per week they exercised and the number of minutes they spent exercising on those days. By multiplying these 2 variables, the number of minutes of total exercise per week was estimated. The survey was structured such that estimation of the proportion of the specific categories of PA already described was not possible. To minimize overreporting of nonaerobic PA, the questionnaire specified that respondents include only “aerobic exercises that increase your heart rate and breathing and/or cause you to sweat.” On the basis of 2008 USDHHS PA guidelines, each respondent's PA level was classified into 1 of 3 groups: meets PA guidelines (>150 min/wk), may meet PA guidelines (75-150 min/wk), or does not meet PA guidelines (<75 min/wk). For most analyses, women who definitely met PA guidelines (>150 min/wk) were compared with women who definitely did not meet PA guidelines (<75 min/wk). To include the full population and determine the relationship between women who exercised less because of hair concerns and the PA levels, the groups were consolidated to reflect women who either definitely meet PA guidelines (>150 min/wk) vs women who may not meet PA guidelines (<150 min/wk).

To assess the relationship between categorical measures, Fisher exact tests were used. Ordinal logistic regression was used to assess the relationship between income and ordinal variables. For the continuous measures, means and SDs are presented and a Wilcoxon rank sum test analysis was used to test for significance. All analyses were performed using SAS, version 9.2 (SAS Institute, Inc).

A total of 123 surveys were distributed to self-identified African American women 21 to 60 years of age. Twenty participants were excluded owing to unreturned surveys or unwillingness/inability to complete the survey. Further analysis was performed on the surveys from the remaining 103 women. The surveyed population was well distributed with respect to age and annual income levels. The mean (SD) age was 42.3 (10.1) years. Age was significantly associated with income (P = .02); specifically, women in the lowest income group (<$20 000 annually) were statistically significantly younger than women who earned $20 000 to $39 000 or greater than $60 000 annually.

Incidental activities (98.1%) were the most commonly reported type of PA. Nearly 45% of women (44.7%) reported participation in aerobic/gym activities, making it the second most commonly practiced type of exercise. Twenty-six percent of women participated in sports-type activities, and only 8.7% of women participated in water activities. Specifically, the most common physical activities included walking (73.8%), housework (69.9%), dance (36.9%), taking the stairs (35.9%), gardening (22.3%), aerobics (22.3%), and jogging (19.4%.) Nineteen women (18.5%) participated in strength training or weightlifting activities.

Thirty-two percent of women exercised 1 to 2 d/wk but frequency of exercise was fairly evenly distributed from 0 to greater than 4 d/wk. Increasing age was associated with fewer days per week of exercise (P = .07). More than half of the women exercised less than 75 min/wk and thus were physically inactive according to the 2008 USDHHS guidelines, whereas 22.3% of women surveyed reported meeting guidelines for sufficient PA (>150 min/wk). The remaining 24.3% of women had indeterminate exercise status by USDHHS guidelines. A substantial 26.2% of women reported 0 min/wk of PA.

Women who were sufficiently physically active (>150 min/wk) were significantly more likely to report participating in sports and aerobic/gym activities than women who were not sufficiently active (<75 min/wk) according to PA guidelines (sports odds ratio, 4.9; 95% CI, 1.7-14.3; P = .005; and aerobic/gym activities odds ratio, 21.5; 95% CI, 5.5-84.2; P < .001).

Daily living was the most commonly cited reason for engaging in PA (61.2%), followed by exercise (51.5%), fun (39.8%), health (37.9%), weight loss (36.9%), work (23.3%), socializing (21.4%), physician recommendation (11.7%), and transportation (9.7%). The motivators for PA also demonstrate a different distribution when considering the categorical proportion of “physically active” women. Respondents who were sufficiently physically active (>150 min/wk) and met PA guidelines were more likely to list weight loss (P = .005), health (P < .001), and exercise (P = .005) as key reasons for their PA. Women who reported “daily living” as the reason for their PA were less likely to meet guidelines for sufficient PA (P = .09).

Most women (62.1%) wore their hair in a relaxed (ie, chemically straightened) style (Table 1). A braided style was worn more commonly in the lower income group compared with women in higher income groups and was also worn significantly more by younger women. Most women washed their hair every 1 to 2 weeks (81.6%) owing to dirtiness (43.7%), itchiness (42.7%), or dryness (21.4%). There was a statistically significant relationship between income and frequency of hair washing: women with higher incomes (>$40 000) tended to wash their hair more frequently than women with lower incomes (<$40 000) (P = .005). More than 40% of the women (42.2%) spent greater than 60 minutes each week maintaining their hair. Women in higher income groups were more likely to spend higher amounts of money on hair care per month (P = .01).

Two-thirds of respondents (67.0%) were happy with the appearance of their hair, but many wished their hair was longer (47.6%), thicker (48.5%), or less dry (30.1%). Women who wished for longer hair were significantly younger (mean age, 40.0 vs 44.3 years; P = .03 by Wilcoxon rank sum test) and women who wished for thicker hair were significantly older (44.7 vs 39.9 years; P = .01 by Wilcoxon rank sum test) than those who did not wish for these hair changes. More than half of the women surveyed reported scalp itching and hair breakage (Table 2). Women who experienced itchy scalp were younger than women who did not (mean age, 40.2 vs 44.6 years; P = .02 by Wilcoxon rank sum test), and women who experienced flaking were younger than women who did not (38.9 vs 43.8 years; P = .04 by Wilcoxon rank sum test). Most women treated their scalp symptoms with over-the-counter or salon treatments; those with hair breakage (P = .046 by Fisher exact test) and flaking scalps (P = .02 by Fisher exact test) were significantly more likely to use over-the-counter scalp treatments. Women who treated their scalps at the salon were significantly younger than women who did not (mean age, 38.5 vs 43.9 years; P = .01 by Wilcoxon rank sum test). Happiness with hair appearance was associated with lower use of prescription topical treatments (P = .03), lower reported hair breakage (P = .001) and loss (P = .005) with normal styling, and decreased avoidance of exercise due to itching or burning (P = .04) (all by Fisher exact test) (Table 3).

Most African American women studied wear their hair in a relaxed or straightened style (Table 1), which could revert back to a more native or kinkier texture when wet. Nearly 40% of study participants (37.9%) reported avoiding exercise at times because of their hair (Table 3). Hair concerns led 35.9% of the surveyed women to avoid swimming/water activities and 29.1% to avoid aerobic/gym activities. Women with normal scalps (not dry or oily) were significantly more likely to participate in aerobic/gym activities than those with scalp complaints (P = .05 by Fisher exact test).Women who participated in aerobic/gym activities were more likely to consider changing their hair to accommodate exercise (P = .07). The most commonly cited hair-related concerns that kept women from exercising were sweating out hairstyle (37.9%) and time to wash, dry, and style hair (22.3%). Women who experienced itching with exercise were younger than women who did not (mean age, 39.4 vs 43.6 years; P = .05 by Wilcoxon rank sum test).

Half of women surveyed had considered modifying their hairstyle to facilitate exercise. Women who were not happy with the appearance of their hair were more likely to consider changing their hairstyle to allow for exercise (P = .06). Styles that women considered to accommodate exercise included ponytail (31.1%), braids (19.4%), cornrows (10.7%), and natural (8.7%). Women with relaxed hair were more likely to avoid exercise because of their hair (P = .06) and were 2.9 times (95% CI, 1.1-7.7; P = .03) more likely to choose a ponytail to accommodate exercise. Women who would change to a ponytail also tended to be younger (P = .02). Women without relaxed hair were 16 times more likely to consider changing to a natural style to facilitate exercise compared with women with relaxed hair (P = .002). Younger women and women in lower income groups were more likely to consider a braided style to allow for exercise.

African American women who avoid exercise because of hair concerns were 2.9 times (95% CI, 0.9-9.4) less likely to be sufficiently physically active (>150 min/wk), with a trend toward significance (P = .08), compared with women who were not sufficiently physically active to meet PA guidelines (<150 min/wk). These findings mirror previous studies^6,18 showing that hairstyle maintenance influences exercise practices of nearly half of African American women.

Hair maintenance in African American women in this study limited their participation in PA with more than half of the women exercising less than 75 min/wk and 26.2% reporting 0 minutes of exercise per week. Many women have several hair care practices in use at one time, including chemical relaxers along with braids or chemical relaxers along with flat ironing and wig use. Younger women tended to use braids more frequently than older women in this study, perhaps suggesting that braided styles are more accepted by younger women. Older women tended to wash their hair more frequently than younger women, which may be because they were able to afford to do so; however, most commonly wash their hair every 1 to 2 weeks, which may contribute to scalp and hair complaints. In this study, a large proportion of the women reported scalp and hair symptoms (54.5% with itching, 50.5% with hair breakage, and 31.7% with scalp flaking and scaling). These findings can help the physician and physician extender in understanding choices that patients make regarding hair care as well as possible recommendations that will be acceptable to patients as part of a treatment regimen for scalp symptoms. Exercise with increased sweating and/or humidity was perceived to exacerbate itching of the scalp by 32.0% of the women in this study. Although others have noted that, for African American women, hairstyle management is a barrier to exercise,^6,18 to our knowledge, the relationship between exercise and provocation of dermatologic conditions has not been explored previously. Skin conditions, particularly diseases of the hair, scalp, and nails, have a high quality-of-life impact that may be equal to or even more pronounced than conditions of other organ systems, including asthma, angina, and hypertension.²² Some studies²³ suggest that this effect on quality of life may be more pronounced in people of color. Thus, patients may modify exercise behaviors to avoid devastating flares of their dermatologic conditions that significantly affect their quality of life.

Beyond exacerbation of scalp and hair symptoms, our study suggested that concerns relating to maintenance of hairstyle (and associated time and money required to maintain hairstyle) were significant barriers to PA for many African American women. Most of the women surveyed (62.1%) wore their hair in a chemically relaxed style, which determined how the hairstyle was maintained by limiting washing their hair to every 1 to 2 weeks. Weekly to every-other-week hair washing may minimize the number of times per week that women want to exercise enough to perspire. A ponytail or braided style used in the days after vigorous exercise before the next hair wash may allow more women to exercise. Further research needs to be performed with the 37.9% of study participants who avoided exercise owing to their hairstyle. One limitation of our study is that our findings may not be generalizable to African American women living in other geographic areas, because some hair care practices can be regional in nature. This study concentrated on this population to understand important barriers to exercise in a group that is at extreme risk of obesity and resultant diseases at a disproportionately higher rate than other ethnicities. Furthermore, our study was conducted before the introduction of the 2008 exercise guidelines, so our study was not equipped to determine whether women who exercised from 75 to 150 min/wk met guidelines for PA, because women were not asked to list how many minutes were spent on moderate vs vigorous activities. Physical activity data were self-reported by participants and thus could be an overestimate or underestimate of their true level of PA. Finally, because some survey participants may have presented to dermatology for evaluation of hair and scalp complaints, there may be oversampling of those with scalp conditions in comparison with the general population.

Exercise is an essential component of weight loss and weight maintenance.^24,25 Although 100% of women in our survey recognized that exercise is important for African Americans and for themselves personally, many barriers made it challenging for them to meet current USDHHS guidelines for PA. Effective strategies to promote PA in African American women, known to disproportionately have obesity and associated sedentary diseases, must include addressing dermatologic barriers to PA with strategies that address hairstyle maintenance. The high percentage of African American women with baseline scalp complaints suggests that dermatologists need to consider these symptoms when providing care for African American women. In addition, dermatologists can discuss hair management strategies that facilitate routinely performing exercise. Future studies delineating whether scalp and hair barriers to exercise exist for other subsets of the population may be helpful.

Correspondence: Amy J. McMichael, MD, Department of Dermatology, Wake Forest University School of Medicine, 4618 Country Club Rd, Winston-Salem, NC 27104 (amcmicha@wakehealth.edu).

Accepted for Publication: October 15, 2012.

Published Online: December 17, 2012. doi:10.1001/jamadermatol.2013.1946

Author Contributions: Drs Hall and McMichael and Ms Swett had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Francis, Whitt-Glover, and McMichael. Acquisition of data: Hall and Loftin-Bell. Analysis and interpretation of data: Hall, Francis, Swett, and McMichael. Drafting of the manuscript: Hall, Francis, Loftin-Bell, Swett, and McMichael. Critical revision of the manuscript for important intellectual content: Hall, Whitt-Glover, and McMichael. Statistical analysis: Swett. Administrative, technical, and material support: Hall, Francis, Loftin-Bell, and McMichael. Study supervision: McMichael.