Introduction
South Africa has the largest population of individuals living with HIV in the world, with 7.2 million people infected as of 2017, 58% of whom are women [
1]. Young women in South Africa are disproportionately affected both by the HIV epidemic and by a high burden of unintended pregnancies. The current annual HIV incidence rate for African women aged 20–34 is 4.5% in South Africa, meaning that four out of every 10 women who are 20 years-old today will have HIV by the time they are 34 [
2]. Furthermore, unintended pregnancies account for one-third of all births in sub-Saharan Africa, nearly half of which occur among women age 15–24.
Risk for HIV and for unintended pregnancy is driven by underlying social and structural barriers including poverty, gender inequality, and a lack of autonomous and consistent healthcare access [
3]. Compared to older women, young women are more likely to both discontinue contraception and use HIV pre-exposure prophylaxis (PrEP) inconsistently [
4‐
6]. Moreover, the number of young people aged 15–24 in South Africa is expected to triple by 2030 [
7]. Thus, in order to stem the tide of HIV among young African women, increased focus on primary HIV prevention and family planning efforts is needed.
The “She Conquers” campaign in South Africa focuses on reducing new HIV infections and unwanted pregnancies among young women [
8]. The most recent national family planning policy calls for use of non-clinical settings for contraception provision and for incorporating HIV testing into contraceptive services, but implementation has been limited [
9]. Expanding access to contraception and PrEP will require a focus on service delivery systems and user preferences to ensure maximum impact [
10].
Hair salons may represent “safe” community spaces where individuals can receive social support. They have been used in the US to promote intimate partner violence screening, but have not been studied for HIV service provision [
11]. Given that South African women congregate regularly in community hair salons, these salons could be promising venues for family planning and HIV prevention services. Our objective was to use qualitative methods to assess the acceptability of nurse-provided contraceptive and PrEP services in hair salons in Durban, South Africa.
Methods
Study Setting and Participants
We conducted individual qualitative interviews with clients (N = 42) and owners (N = 10), and focus groups with stylists (N = 43) in hair salons in and around Umlazi, an urban township of nearly one million people outside Durban [
12‐
14]. Umlazi is the second most densely-populated township in South Africa with a single hospital in its catchment area [
14]. 80% of owners, 93% of stylists, and 100% of clients were female and the average age of each group was 40, 30, and 27 years. Inclusion criteria included: Age ≥ 18 years, English or isiZulu speaking, and able and willing to provide informed consent [
15]. Salon owners, stylists, and clients were recruited from a convenient sample of hair salons in Umlazi Township and neighboring communities and were approached by a bilingual (English/isiZulu), female research assistant to assess their interest in participating in an in-depth interview or focus group. Study procedures were approved by the University of KwaZulu-Natal Biomedical Research Ethics Committee (BE388/16) and the Partners (Massachusetts General Hospital/Brigham and Women’s Hospital) Institutional Review Board (Protocol 2016-P-001268, Boston, MA).
Measures
We used semi-structured interview and focus group guides, developed using guidelines by Huberman and Miles [
16] for qualitative data collection. Our questions were informed by domains derived from the Anderson model of health service utilization [
17], a review of recent literature on PrEP and contraceptive services, and specific domains believed to be of importance to the study team. Interviews with clients focused on questions about contraceptive use and preferences, knowledge about PrEP, and opinions on offering contraceptive and PrEP services in hair salons. Interviews with hair salon owners focused on topics including roles of hair salons in their communities, programmatic questions about offering these services at hair salons (e.g. feasibility and resources needed, effects on business, and overall comfort level). We probed stylists on a range of topics, focusing on their perceived role of hair stylist in the Umlazi community, their comfort with intervention participation, and useful resources for supporting a health intervention in the salon (e.g. scripts or promotional materials). Questions were open-ended to avoid bias and encourage generation of novel content. Sample questions and probes for each interview and focus group guide are provided in Table
1.
Table 1
Sample study content areas and questions/probes
Clients |
Warm-up questions | • What do you think are the major health care services that young women in Durban need? • Of the services that you mentioned, are there any that you think you would be interested in receiving at the hair salon? |
Contraceptive care/family planning | • Could you describe your current contraceptive use (including you current contraceptive method, duration of use, how you chose your current method, your perceived need for contraception, and your interest in contraception)? • What contraceptives are most attractive to you (oral contraceptive pills, injectables, hormonal subdermal implants, intrauterine devices)? • Do you see hair salons as acceptable venues for contraception access and support? Why or why not? • What are your preferences for who to hear reliable information about contraception from at the salon (i.e. hair stylist, peer mentor, nurse)? Why? • Do you think having adherence support for your contraception would be helpful? |
HIV testing and PrEP | • What have you heard about PrEP? • How would you feel about HIV counseling and PrEP being offered to clients at the hair salon? • How do you think this would affect salon activities? • What strategies would help you and other clients feel more comfortable and willing to undergo testing at the salon (i.e. park mobile tester right outside the salon, set up private testing area in a back room, etc.)? |
Stylists | |
Warm-up questions | • How do you think people perceive the role of the hair stylist in the Durban community? • How do you perceive your role as a hair stylist? • How would you describe the relationships you have with your clients? |
Programmatic questions | • Do you think discussion health topics and offering services to clients at the salon is feasible? • How do you think this would affect logistics and flow of clients through the salon? • What kind of support might make you feel more comfortable? For example, having a health care provider on site to answer questions |
Contraceptive care/family planning | • What kinds of things can make it easy for women to get access to contraception? What kinds of things can make it hard? • What resources might be useful to you as stylists for supporting offering contraception in the salon (i.e. scripts, promotional materials, posters, etc.)? • How could these be implemented? • What do you think about offering some sort of incentive or compensation for offering and accepting contraception at the salon? • Do you think having adherence support for contraception would be helpful? |
HIV testing and PrEP | • What have you heard about PrEP? • How would you feel about having HIV testing services offered at the hair salon? • What suggestions would you have about the set-up for offering HIV testing services at the salon? |
Owners |
Rapport building questions | • What do you think are the major health care services that young women in Durban need? • How would you describe the role of hair salons in the Umlazi community? |
Programmatic questions | • What do you see as potential challenges to discussing health topics with or offering health services for hair salon clients? • Would you feel comfortable having stylists talking with your clients about a health topic? • What resources might be useful for supporting a health intervention in the salon (i.e. scripts, promotional materials, posters, etc.)? Do you have any ideas about how these could be implemented? • What resources do you think you as a salon owner would need if the salon implemented a health intervention? • What are your ideas for these potential incentives or compensation for the salon owners? Stylists? Clients? |
Contraceptive care/family planning | • How do you feel about the possibility of offering contraceptive services in the hair salon setting? • Tell me about how you think clients would respond to the possibility of accessing contraception at the hair salon? |
HIV testing and PrEP | • What have you heard about PrEP? • How do you feel about the possibility of offering HIV prevention services such as PrEP in the salon setting? • Would you feel comfortable with stylists giving clients information about PrEP? |
We paid each participant ZAR 100 for their time. Interviews for client and owners lasted 45–60 min; focus group discussions lasted 1–2 h.
Analyses
Interviews and focus groups were audio-recorded, transcribed, and translated from isiZulu to English by an independent transcriptionist. Content analyses were conducted to uncover themes related to three category domains: (1) facilitators of and (2) barriers to providing contraception and PrEP in hair salons and (3) program implementation specifics to assess the acceptability of the service and to inform designing future interventions. The analysis was done using an iterative multi-step process. We identified categories and subcategories, and developed a codebook based on those categories. The codebook was organized according to our study question and was aimed at identifying what participants viewed as barriers and facilitators to offering contraceptive services and/or PrEP services in hair salons in Durban, South Africa. Nvivo 12 (2018) was used to code and organize data.
Two coders (SCF and LM) analyzed the first 10% of the transcripts from each group (clients, stylists, and owners) to ensure independent, consistent codebook use. The coders compared results from each phase of their analyses and discussed discrepancies until a resolution was reached. Categories and subcategories outlined in the codebook were continually reexamined to check for applicability and consistency in codebook interpretation. The authors also discussed findings during analysis to ensure that interpretation of the data was not being influenced by perceived theories. An audit trail of coding templates and discussions about the data and computerized coding was kept. Oversight of the qualitative process was provided by CP and the topic-related content was reviewed by IVB and CP.
Discussion
This study explored barriers to and facilitators of offering contraceptive and PrEP services in hair salons in Durban, South Africa. Overall, clients, stylists, and owners were interested in bringing contraceptive and PrEP services to hair salons and believed that it would be possible to successfully implement this intervention. Participants indicated that they saw potential for hair salons to be innovative venues for delivering important healthcare services to women, citing their convenience and supportive, female-dominated environment. Participants did foresee challenges with the program, especially establishing legitimacy to garner trust and ensuring client privacy.
Community interventions can be attractive alternatives to clinic-based care, especially in South Africa where clinics are often overcrowded and inconveniently located. Our proposed intervention aims to use hair salons as “safe” spaces within communities where women can access contraceptive and PrEP services. In the US, hair salons have been successfully used as venues for a variety of health-related interventions. One 2004 study found that clients often discuss sensitive health-related topics with stylists and found that hair salons offered a feasible venue to discuss healthcare matters [
11]. A recent study showed the women would disclose experiences of intimate partners violence to stylists in hair salons [
18]. Hair salon-based health interventions have yet to be implemented or studied in Sub-Saharan Africa, although our findings suggest that there may be a similar culture around discussing personal topics. A meta-analysis of health promotion and education interventions in hair salons and barbershops in the US found that 73% of them showed significant results [
19]. In these interventions, stylists and barbers were often trained to deliver healthcare education to clients, an approach that showed success across health topics (including cancer, hypertension, diabetes, and general wellness). Most of the outcomes, however, were about increased knowledge on health topics, and did not include interventions in which clients participated in an ongoing program or service. However, one barbershop-based intervention aimed at reducing systolic blood pressure in non-Hispanic black men in the United States found that a barber-promoted and pharmacist-led drug therapy led to significantly larger blood pressure reduction than when barbers encouraged patients to make lifestyle modifications and a doctor’s appointment [
20]. This suggests that service-oriented interventions in haircare settings can be successful. While service-oriented hair salon interventions have yet to be studied, our research suggests that they are feasible.
A hair salon-based intervention may ameliorate common barriers to PrEP uptake and adherence among young women in South Africa. Women often worry about the stigma associated with taking PrEP. They worry that they might be falsely identified as HIV positive [
21] and/or that they will be perceived by others as sexually active [
22]. In addition, a dearth of resources and access to reproductive services for women and a lack of social support have added additional barriers to uptake and adherence [
22]. Women also cite concerns about PrEP’s side effects as a reason for non-adherence [
21]. Through our planned intervention, we seek to address many of these barriers by increasing accessibility to services at a community-level and by offering services in a “safe,” comfortable environment where women receive social support and education on the services provided by people with whom they already have close relationships. Additionally, the female-dominated atmosphere, where participants felt there was acceptance and understanding of the importance of these services, suggests that offering contraception and PrEP in hair salons could be a helpful way to reduce stigma and focus on prevention as part of wellness. Participants worried about the potential side effects of PrEP and indicated that having pamphlets and posters to properly educate clients would help establish program legitimacy and assuage these concerns.
We present a novel and viable approach to address some of the most pressing public health concerns facing women in South Africa through assessing the feasibility of offering PrEP and contraceptive services in hair salons. These qualitative data can directly inform implementation of this intervention. Such an intervention needs to emphasize privacy, convenience and support for participants and be perceived as legitimate and trustworthy. Privacy can be prioritized through creating a separate space for health-related services, while remaining associated with the salon and maintaining the salon environment. Clients were open to both private rooms and mobile vans as potential spaces for services; owners were concerned about space issues associated with private rooms while clients did generally prefer the idea of a mobile van. Posters displayed in salons and pamphlets distributed to interested clients can establish legitimacy and incorporating positive messaging and destigmatizing campaigns into these materials could encourage and maintain an atmosphere distinct from those at clinics. While clients often cited nurses as mean and rude, they were important to involve for legitimacy. It may help to provide additional training to nurses to mitigate this dichotomy. We can also provide training for stylists and maintain a nurse on site to deliver injections, perform HIV testing, and dispense PrEP. Participants felt mixed about offering incentives to program participants, which will need to be considered as something that may impact implementation.
This study should be considered in the context of its strengths and limitations. We sampled participants with a variety of perspectives and roles (clients, stylists, and owners) from multiple different hair salons in Umlazi. We asked open-ended questions in a semi-structured format that allowed participants to explore subjects more in depth if they wished, but also created a baseline level of comparability between participant responses. We did not ask participants to report their HIV status, which may have influenced their views on HIV testing and PrEP services. Questions about willingness and interest in PrEP services may have been influenced by the participants current HIV status. Pre-existing knowledge of PrEP was limited. Therefore, study staff had to explain what PrEP was, and the centrality of HIV testing to PrEP provision. While women under 18 years are at also high risk for unintended pregnancy and HIV and may have their own unique set of barriers and facilitators to hair salon-based services, they were not included in our sample. Despite these limitations, this study conveys an overall willingness of clients to participate in receiving contraceptive and PrEP services in hair salons and eagerness of owners and stylists to offer such services to women in Umlazi. In this qualitative study of hair salon owners, stylists, and clients in Umlazi Township, South Africa, convenience and a conducive environment were noted as facilitators to receiving health services in hair salons. Establishing privacy for HIV testing and program legitimacy through advertising will be paramount. Hair salons represent an innovative venue for reaching young women at high-risk for unintended pregnancy and HIV infection by capitalizing on the focus on convenience and comfort that salons provide.
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