Journal of Community Health (2019) 44:1150–1159
Contraception, HIV Services, andPrEP inSouth African Hair Salons:
AQualitative Study ofOwner, Stylist, andClient Perspectives
IngridV.Bassett1,2,3,4· SabinaGovere5· LuciaMillham2· SimoneC.Frank2· NosiphoDladla5· HilaryThulare5·
Published online: 6 July 2019
© The Author(s) 2019
Women experience challenges engaging with the healthcare system, but frequently utilize hair salons; these are promising
venues for family planning and HIV prevention services. Our objective was to assess the acceptability of nurse-oﬀered contra-
ceptive and PrEP services at hair salons in Durban, South Africa. We interviewed salon owners (N = 10) and clients (N = 42)
and conducted focus groups with hair stylists (N = 43 stylists; 6 focus groups across ﬁve hair salons) to explore barriers and
facilitators to providing contraception and PrEP in salons. After developing a codebook, we performed content analysis to
identify themes within each conceptual area; 10% of transcripts were coded by two coders to ensure reliability. Content was
analyzed according to the following categories: (1) facilitators of and (2) barriers to utilizing these services, and (3) factors
to consider for program implementation. Participants identiﬁed convenience and female-oriented, supportive atmosphere
as facilitators to oﬀering HIV and contraceptive services in salons. Owners and stylists noted that establishing legitimacy
was important for program success, including providing promotional pamphlets and employing nurses. Clients cited privacy
concerns surrounding HIV testing in a public space as a signiﬁcant barrier to using these services. Overall, participants were
enthusiastic about the program. Convenience and a conducive environment were noted as facilitators to receiving health
services in the hair salon; attention will have to be directed to establishing privacy and program legitimacy. Hair salons
represent an innovative venue for reaching young women at high-risk for unintended pregnancy and HIV infection.
Keywords South Africa· Contraception· HIV prevention· Young women· Hair salon
South Africa has the largest population of individuals liv-
ing with HIV in the world, with 7.2 million people infected
as of 2017, 58% of whom are women . 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 20years-old today will have HIV
by the time they are 34 . Furthermore, unintended preg-
nancies 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 pov-
erty, gender inequality, and a lack of autonomous and con-
sistent healthcare access . Compared to older women,
young women are more likely to both discontinue con-
traception and use HIV pre-exposure prophylaxis (PrEP)
* Ingrid V. Bassett
1 Division ofInfectious Diseases, Massachusetts General
Hospital, 100 Cambridge St, 16th Floor, Boston, MA02114,
2 Medical Practice Evaluation Center, Massachusetts General
Hospital, Boston, MA, USA
3 Harvard Medical School, Boston, MA, USA
4 Harvard University Center forAIDS Research, Harvard
University, Boston, MA, USA
5 AIDS Healthcare Foundation, Durban, SouthAfrica
6 Behavioral Medicine Program, Department ofPsychiatry,
Massachusetts General Hospital, Boston, MA, USA
1151Journal of Community Health (2019) 44:1150–1159
inconsistently [4–6]. Moreover, the number of young peo-
ple aged 15–24 in South Africa is expected to triple by
2030 . 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 . 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 . Expanding access to contraception and PrEP
will require a focus on service delivery systems and user
preferences to ensure maximum impact .
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 pro-
vision . 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.
Study Setting andParticipants
We conducted individual qualitative interviews with cli-
ents (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 Dur-
ban [12–14]. Umlazi is the second most densely-popu-
lated township in South Africa with a single hospital in
its catchment area . 80% of owners, 93% of stylists,
and 100% of clients were female and the average age of
each group was 40, 30, and 27years. Inclusion criteria
included: Age ≥ 18years, English or isiZulu speaking, and
able and willing to provide informed consent . Salon
owners, stylists, and clients were recruited from a conveni-
ent sample of hair salons in Umlazi Township and neigh-
boring 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 Hos-
pital/Brigham and Women’s Hospital) Institutional Review
Board (Protocol 2016-P-001268, Boston, MA).
We used semi-structured interview and focus group
guides, developed using guidelines by Huberman and
Miles  for qualitative data collection. Our questions
were informed by domains derived from the Anderson
model of health service utilization , 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 contra-
ceptive 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 styl-
ists 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 Table1.
We paid each participant ZAR 100 for their time. Inter-
views for client and owners lasted 45–60min; focus group
discussions lasted 1–2h.
Interviews and focus groups were audio-recorded, tran-
scribed, and translated from isiZulu to English by an inde-
pendent 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 identi-
fying 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 cod-
ers compared results from each phase of their analyses
1152 Journal of Community Health (2019) 44:1150–1159
Table 1 Sample study content areas and questions/probes
Content area Sample questions/probes
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, dura-
tion of use, how you chose your current method, your perceived need for contraception, and your interest
• 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.)?
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 pro-
vider 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?
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, promo-
tional 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 inter-
• What are your ideas for these potential incentives or compensation for the salon owners? Stylists?
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
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
• Would you feel comfortable with stylists giving clients information about PrEP?
1153Journal of Community Health (2019) 44:1150–1159
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 interpre-
tation of the data was not being inﬂuenced by perceived
theories. An audit trail of coding templates and discus-
sions 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.
Demographic data for clients, stylists, and owners are pre-
sented in Table2. We organized data from 42 client inter-
views, 6 focus groups with 43 stylists, and 10 owner inter-
views, into our three category domains. Overall, clients,
stylists and owners, as groups, most often reported similar
views on common barriers and facilitators to providing con-
traceptive and PrEP services at hair salons.
Participants identiﬁed the convenience of being able to
receive contraception and PrEP services at the same loca-
tion and at the same time as their hair appointment as a
major advantage to accessing these services in salons. Cli-
ents often noted that they prioritize their salon appointments
more than they prioritize clinic visits. One 23year-old (y/o)
client explained that her “biggest priority [was her] hair;”
another (35 y/o) explained that, “most women try by all
means to meet their salon appointments so it would help
if we can also receive our contraceptives [at the salon].” A
stylist agreed: “most people would rather do their hair than
go to the clinics.” One 28 y/o client explained that her salon
appointment had so much importance because attending a
salon appointment provided visible return on investment.
She explains that women understand their beauty, which can
be linked with self-esteem and/or self-worth, through the
state of their hair: “As working women we hardly get time
to go to the clinic but with the salon we don’t take chances.
We make it a must that we go to the salon… as women we
value our beauty through our hair styles.” A 29 y/o client
echoed this sentiment, explaining that while women “can’t
go to the clinic and wait for 3h for their turn … At the salon
people know they want to look beautiful, so they end up not
minding about the time.” An appointment at a hair salon
has tangible value that women can see, an appointment at a
clinic feels like long hours for little perceived beneﬁt.
Table 2 Demographic characteristics
Variable N %
A. Clients (N = 42)
M = 27.1 – –
SD = 6.3 – –
Black (South African) 41 98
Black (Other African) 1 2
Female 42 100
Is this salon mostly visited?
Yes 31 74
No 9 21
Did not answer 2 5
Time spent in salon (hour)
< 1 6 14
1 20 48
2 11 26
3 5 12
B. Stylists (N = 43)
M = 29.6 – –
SD = 5.1 – –
Black (South African) 33 77
Black (Other African) 9 21
Did not answer 1 2
Female 40 93
Male 3 7
Length of time working at salon (months)
0–12 13 30
13–24 6 14
25–48 11 26
> 48 12 28
Did not answer 1 2
Works at multiple salons
Yes 36 84
No 6 14
Did not answer 1 2
Number of working days per week
5days/week 1 2
6days/week 20 47
7days/week 21 49
Did not answer 1 2
Number of unique clients per week
0–10 clients/week 6 14
11–25 clients/week 17 40
26–50 clients/week 15 35
> 50 clients/week 3 7
Did not answer 2 4
1154 Journal of Community Health (2019) 44:1150–1159
Additionally, salons are more geographically convenient
than clinics and oﬀer more ﬂexible hours. Salons are often
located in commercial areas where there are fewer clinics,
but which are more convenient to day-to-day activities.
One stylist noted that this convenience could favor resi-
dents who might not normally be salon customers: “Even
if someone is not coming to the salon but works close
to the salon, they can come and get their pills from here
because they do not have time to go to the clinic.” Addi-
tionally, salons are often open on weekends and after busi-
ness hours to serve clients who work. One stylist noted that
“most people are oﬀ on weekends and clinics are closed on
weekends. So if health services are oﬀered at the salons,
the clients would beneﬁt a lot.”
Stylists and owners agreed with clients that oﬀering
contraceptive and PrEP services at hair salons would be
convenient, adding that they often do not have enough
time to go to the clinics themselves because of their work.
One 31 y/o female owner explained that “the problem why
[sic] we hardly go to the clinic is because … it clashes
with salon activities;” a stylist felt similarly: “even as an
employee of the salon I do not get the time to go to the
clinic so I can [get services] from the salon.”
Clients, stylists, and owners also identiﬁed the uniquely
supportive and peaceful atmosphere found at salons as a
facilitator to using these services. Women feel that there is
a mutual understanding and support at a salon that may not
be present elsewhere. One 25 y/o client explained that, “at
the salon even when you are waiting you are with people
that you know … [this tends] to make you not worry about
the time that you spending [sic] at the salon.” In addition,
oﬀering PrEP and contraceptives in this environment is
not incongruous with topics already discussed at salons.
One 20 y/o client explained that “the topics at the salon
amongst women always related to [HIV and contracep-
tion],” and a 22 y/o client noted that at the salon, “we
all have similar interests when it comes to female health
Many clients, stylists, and owners focused on how the
atmosphere at the salon existed because it was a female-
dominated space “where women come together,” “feel safe
with other women,” and where “the privacy in the salon is
between us women. You hardly ever see guys in the salon.”
In addition, clients noted a mutual respect for privacy
between women that might be lacking in a more heteroge-
I think I would be comfortable to receive [these ser-
vices] because there are few men at the salon… if we
go to clinics and you see someone who knows you they
might think that you are there for HIV. (22 y/o)
In addition, women talked about the mutual understand-
ing that they, as women, have for the health problems that
they face that again, might not be present outside of this
female-dominated space: “I can get my contraceptives at the
salon because we all women … and we all understand that
this is a normal thing (28 y/o).
Table 2 (continued)
Variable N %
C. Owners (N = 10)
M = 40.3 – –
SD = 7.6 – –
Black (South African) 6 60
Black (Other African) 4 40
Female 8 80
Male 2 20
Length of time owning salon (years)
0–5years 4 40
6–10years 3 30
> 10years 3 30
Length of stylist employment
< 1year 2 20
1–2years 3 30
3–5years 3 30
> 5years 1 10
Did not answer 1 10
Number of new clients per week
20–75 6 60
76–150 2 20
> 150 1 10
Did not answer 1 10
Number of salon chairs
1–5 2 20
6–10 7 70
> 10 1 10
Number of stylists
1–5 8 80
6–10 – –
> 10 1 10
Did not answer 1 10
Owner owns multiple salons
No 8 80
Yes 2 20
M mean, SD standard deviation
1155Journal of Community Health (2019) 44:1150–1159
Clients’ focused on salons as good places for women’s
health services because of the dearth of men and because
as women they understand the importance of these services.
The salon atmosphere was enhanced by salon personnel.
Clients and stylists both noted a supportive client-stylist
relationship that can foster meaningful conversations. One
28 y/o client explained that she would prefer to get informa-
tion about contraceptive and PrEP services from her stylist
because “we have developed a relationship with the styl-
ist.” The stylists feel similarly, describing clients as friends
or family, suggesting that these relationships are not only
professional, but personal—built on trust and respect: “My
clients are my friends… and my sisters,” “we take them as
family,” and “we become counsellors to [clients]…when
you are with a client for so many hours, even the problems
or situations they have in their lives you can talk to them
and advise them.” Overall, the stylists see clients as friends
and family; clients divulge personal information and stylists
often try to oﬀer advice and assistance on matters outside
of hair care.
This supportive and safe atmosphere was contrasted with
clinic experiences. A 35 y/o client would rather talk to her
stylist because “I am comfortable around my stylist. The
nurses are always intimidating and rude.” A stylist also saw
this dichotomy, “we would have to be diﬀerent [than the
nurses] … we do everything that the nurses do not do. We
have to be kind to the clients and patients.”
One stylist also noted there may be an added challenge to
maintaining a comfortable and supportive atmosphere while
instituting these services at the salon. The stylist expressed
concern that “there are those people who will no longer
want to come to [the salon]… some will [talk] negatively
about us to other people saying that the salon no longer does
hair but now they teaching about HIV.” Given that partici-
pants indicated the clinics’ unfavorable atmosphere contrib-
uted to their reluctance to go, maintaining an atmosphere
at the salon that is diﬀerent from the clinic is particularly
Clients, stylists, and owners noted that establishing legiti-
macy is paramount to program success. One 27 y/o client
indicated that people are prone to question the legitimacy
of the program, “people would think, how do they trust the
needles used for injections?.” Participants used words like
“joke” or “scam” to describe how the program could be per-
ceived if it was not done in a way that proved to people that
it was “genuine,” “serious,” “legit,” or “well thought of.”
Solutions to overcome this barrier included education
materials, in the form of posters, pamphlets, and trainings
for the stylists. A stylist suggested that posters and pam-
phlets will “show clients that this is a genuine initiative.”
A 42 y/o male owner argued that these materials were nec-
essary for program legitimacy, “If we run the programme
without poster or pamphlets, people would think this is a
joke or a scam.” A 34 y/o client indicated that “oﬀering a
voucher would make people think what you are oﬀering is
serious.” Overall, participants suggested that having tan-
gible aspects to the program to “show” people what the
program entails would establish legitimacy.
It was also important that clients understood partici-
pation was voluntary. One stylist viewed this as a major
barrier: “the biggest challenge would be in convincing
people…that they are not forced to use this programme.”.
Moreover, there may be some hesitation about a program
that is oﬀering healthcare services that include prescrib-
ing medication outside of a clinic: “people would have to
understand that no one is forced to get tested or use the
medication” (24 y/o).
A stylist noted that having resources to educate clients
about the program would help:
I think there should be trainings and counselling that
educates people on the beneﬁts of this programme,
this way… they will understand that this programme
is aimed at helping them.
Stylists felt they needed training to perform their role in
a way that would engender trust in the clients. One 22 y/o
client noted that people may be remiss to trust stylists, “a
stylist is just a stylist and has no knowledge of health issues.”
Clients can often view them as uneducated: “some of the
clients have very low regard for us… since we do hair, we
are uneducated,” and another, “some people think we just
remove dandruﬀ.” Thus, ensuring that stylists are knowl-
edgeable and have proper training is important; one stylist
explained, “I think certiﬁcates will [assure] clients… that as
stylists we know what we are talking about.”
Lastly, while stylists were interested in oﬀering and
explaining these services to their clients, participants
across groups felt that having a nurse deliver the services
would be the best way to promote trust and to maintain
some separation between salon and healthcare-oriented
activities. One 25 y/o client suggested that, “maybe [the
stylists] can just prep us up for it… but when we have to
do the actual test it can be the peer advisor or nurse so that
your test results can be private and conﬁdential.” Clients
explained that there is an assumption that nurses will be
“knowledgeable in health-related matters” and have more
“experience with health issues,” and that this would garner
more trust. One 29 y/o client explained: “People would see
it’s a nurse and assume the nurse would do the right thing.”
Stylists also mentioned uniforms as a way of establishing
legitimacy both for themselves (e.g. caps and T-shirts),
1156 Journal of Community Health (2019) 44:1150–1159
and also for the nurses: “if there is someone in uniform…
even clients would take the programme seriously.”
Clients were most concerned about privacy as a barrier
to implementing contraceptive and PrEP services in hair
salons, speciﬁcally regarding HIV testing. Stigma was at
the forefront of participants concerns. Clients explained
that they would be worried about someone they know
learning private information about their sexual activity
because they saw them at the salon:
Some people would just not want to be seen using
this service of contraception because they think peo-
ple would know that they are having sex. (29 y/o)
Imagine you are here to get your prevention pills
from the salon and you bump into someone that you
know… everyone would know that you [sic] getting
contraception from the salon. (24 y/o)
Multiple clients also worried that it might be diﬃcult to
keep the results of an HIV test private in a salon setting:
If someone gets tested and they ﬁnd that they are
HIV positive and then now come out of the testing
room crying… people notice that. (24y/o)
In addition, some clients worried that stylists might
gossip. One 25 y/o client explained, “hair stylists are not
known for their ability to keep secrets. Stylists are always
talking.” Overall, participants worried about losing con-
trol of how information about them is shared by using
services at a salon where others might know and observe
them. These participants were outliers compared to the
larger portion of participants who felt that oﬀering ser-
vices amongst women and supportive stylists would be a
Participants referenced two main solutions to address the
issue of privacy in the salon: a private room within the salon
or an outside space outside, adjacent to the salon (like a
mobile van). Clients who advocated for a private room inside
the salon thought it would help ensure utilization:
It would be better if it is inside because people would
know while they wait they can go to the nurse and get
tested… outside it would take too much time. (29 y/o)
As this participant suggests, oﬀering these services even
just outside the salon could be less convenient because it
adds an additional step in a diﬀerent location, which may
be problematic because participants saw convenience as a
major facilitator of program success. Private rooms do pose
a logistical issue; some salons do not have existing spaces
that could be used as a private room for this purpose.
Clients who advocated for a mobile van liked the option
of going to the mobile van without anyone from the salon
I would prefer it if there was a mobile van because if I
get tested and ﬁnd out that I am HIV positive you can
just put me in the van and give me proper counsel-
ling… if they had a private room here in the salon, I
would just come out of that room crying so everyone
would know what happened. (22 y/o)
Owners also noted that the mobile van would be good
solution to address the lack of extra space in many salons.
At the same time, a mobile van would be more visible to
If I tell a client to go to the tent and get tested, when
the client comes back from the tent I will be able to
see if everything is not well…everyone outside will
see that this person received bad news. However, if a
client tests inside the salon, not many people will see
that this person has received bad news. (stylist)
Overall, participants are interested in incorporating this
service as discreetly as possible and ensuring privacy for
Participants felt that incentives would be beneﬁcial to pro-
gram enrollment, if not necessary, to garner interest among
clients. One client noted that incentives have become an
expected part of research:
People, patients, or clients expect to get something
[from research] because most of the time research has
something to oﬀer. (24 y/o)
Others indicated that incentives would help overcome the
barrier of legitimacy, “[incentives] would make people think
what you are oﬀering is serious” (34 y/o client) and would
be an eﬀective way to motivate participants, “free things
give better motivations” (24 y/o client).
On the other hand, stylists in particular did not feel that
incentives were necessary—clients should want to partici-
pate in this program because it is aimed at improving their
health and wellbeing. As one stylist explained, “At the end
of the day, this is your life, you need to do what is best for
yourself, not because there is [sic] incentives oﬀered.” A
22 y/o client echoed that she did not think that incentives
would help to accomplish the programs goals, “you cannot
buy people to take better care of themselves.”
Participants oﬀered a variety of ideas for incentives,
beyond money. Many suggested vouchers for airtime or
1157Journal of Community Health (2019) 44:1150–1159
food; others oﬀered ideas more tailored to the program,
like sanitary products or hair styling vouchers. Some cli-
ents thought that oﬀering sanitary products could both oﬀer
something free while simultaneously align with the pro-
gram’s intentions to promote women’s health—“instead of
bring [sic] us stuﬀ just to make us happy, you can bring us
feminine stuﬀ that would also educate us” (25 y/o). One styl-
ist noted that: “Every girl has a desire to go to the salon but
some cannot aﬀord” (24 y/o). Vouchers for salon services of
products would help women overcome ﬁnancial barriers to
going to the salon and could simultaneously promote easier
access to the health services oﬀered. Owners mentioned that
they would want reimbursement for use of the salon space
and stylists indicated that they would want extra pay and/
or T-shirts and caps to identify themselves as part of the
Overall, participants liked the idea of receiving personal
SMS messages and having WhatsApp groups as adherence
supports. Clients preferred SMS messages for direct adher-
ence motivation because they are more private. One client
felt that an SMS could also serve as an automated daily
reminder for women on PrEP to take their medication. A few
participants also noted that SMS would be more accessible
than WhatsApp given data constraints; “WhatsApp will be
a problem because I sometimes run out of data. I can receive
an SMS even if I do not have data” (35 y/o client).
WhatsApp groups were viewed as a tool that could foster
community and provide support. This support could come
in the form of “sharing [their] programmes and life experi-
ences” (18 y/o client) or as a place for women to help one
another problem solve, “if a participant is having problems
with the injection or pills, we can use the WhatsApp group
to share ideas on what can be done” (stylist). Overall, partic-
ipants expressed interest in both personalized SMS remind-
ers and WhatsApp support groups as options for adherence
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 suc-
cessfully implement this intervention. Participants indicated
that they saw potential for hair salons to be innovative ven-
ues 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 pro-
posed intervention aims to use hair salons as “safe” spaces
within communities where women can access contracep-
tive 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 dis-
cuss sensitive health-related topics with stylists and found
that hair salons oﬀered a feasible venue to discuss healthcare
matters . A recent study showed the women would dis-
close experiences of intimate partners violence to stylists in
hair salons . 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 cul-
ture 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 . 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 well-
ness). Most of the outcomes, however, were about increased
knowledge on health topics, and did not include interven-
tions 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
. 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 asso-
ciated with taking PrEP. They worry that they might be
falsely identiﬁed as HIV positive  and/or that they will
be perceived by others as sexually active . 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 . Women also cite con-
cerns about PrEP’s side eﬀects as a reason for non-adherence
. 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 sup-
port and education on the services provided by people with
whom they already have close relationships. Additionally,
1158 Journal of Community Health (2019) 44:1150–1159
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 indi-
cated that having pamphlets and posters to properly educate
clients would help establish program legitimacy and assuage
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 quali-
tative data can directly inform implementation of this inter-
vention. 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 dis-
tributed to interested clients can establish legitimacy and
incorporating positive messaging and destigmatizing cam-
paigns 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-exist-
ing 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 18years 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 will-
ingness 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 cli-
ents in Umlazi Township, South Africa, convenience and a
conducive environment were noted as facilitators to receiv-
ing 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 preg-
nancy and HIV infection by capitalizing on the focus on
convenience and comfort that salons provide.
Acknowledgements We would like to acknowledge our study par-
ticipants, particularly the salon owners who opened their doors and
hearts to this idea. This study was funded by the US National Institute
of Allergy and Infectious Disease (K24AI141036), the Graham Fam-
ily, and the Weissman Family MGH Research Scholar Award. The
contents of this publication are solely the responsibility of the authors
and do not necessarily represent the oﬃcial views of the US National
Institutes of Health.
Funding This study was funded by the US National Institute of Allergy
and Infectious Disease (K24AI141036) (IVB), the Graham Family,
and the Weissman Family MGH Research Scholar Award (IVB). The
contents of this publication are solely the responsibility of the authors
and do not necessarily represent the oﬃcial views of the US National
Institutes of Health.
Compliance with Ethical Standards
Conflict of interest The authors declare that they have no conﬂict of
Ethical Approval All procedures performed this study involving human
participants were in accordance with the ethical standards of the insti-
tutional and national research committee (Partners Human Research
Committee, Protocol #2016P001268 and Biomedical Research Ethics
Committee (University of Kwazulu-Natal), Reference No. BE388/16)
and with the 1964 Helsinki declaration and its later amendments or
comparable ethical standards.
Informed Consent Informed consent was obtained from all individual
participants included in the study.
Open Access This article is distributed under the terms of the Creative
Commons Attribution 4.0 International License (http://creativecom-
mons.org/licenses/by/4.0/), which permits unrestricted use, distribu-
tion, and reproduction in any medium, provided you give appropriate
credit to the original author(s) and the source, provide a link to the
Creative Commons license, and indicate if changes were made.
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