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ORIGINAL ARTICLE
Year : 2023 | Volume
: 30
| Issue : 1 | Page : 53-60
A community-based study of hair care practices, scalp disorders and psychological effects on women in a Suburban town in Southwest Nigeria
Olusola Olabisi Ayanlowo, Erere Otrofanowei
Department of Medicine, College of Medicine, University of Lagos/Consultant Physician, Lagos University Teaching Hospital, Lagos, Nigeria
Correspondence Address:
Erere Otrofanowei
Department of Medicine, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Lagos
Nigeria
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/npmj.npmj_294_22
Introduction: The scalp hairs on an average African is dry with low tensile strength and a tendency to break easily. This is mostly due to poor penetration of the natural oils on the scalp and the very curly hair texture. Various techniques developed to manage African hair are associated with certain hair and scalp disorders and are sources of distress. Objectives: This was a cross-sectional survey to compare natural African hair and chemically processed (relaxed) hair to determine the effect of hair care and grooming practices on common scalp disorders and the psychological effect in Nigerian women. Subjects and Methods: Questionnaires were administered to women at the market, churches and outreaches with many women in attendance to document the hair grooming practices, common scalp symptoms and psychological effects experienced. They were also examined for the presence of seborrhoeic dermatitis and traction alopecia. Results: The study involved 452 women (62.17%) with relaxed hair and 275 women (37.83%) with natural (untreated) hair. Women with relaxed hair experienced significantly more flaking of the scalp (P = 0.046, x2 = 6.16), hair breakage (P = 0.023, x2 = 11.35) and hair loss (P = 0.020, x2 = 7.87) than those with natural hair. The most common psychological effects of hair scalp disorders in all participants were feeling of uneasiness 142 (19.5%), frustration 49 (6.7%), poor body image 40 (5.5%) and anger 38 (5.2%). Significantly more women with relaxed hair experienced moderate hair loss from traction than women with natural hair (P = 0.014, x2 = 8.52). Conclusion: Nigerian women experienced clinical and psychological distress consequent to their hair grooming practices. Individuals with relaxed hair had more physical symptoms, hair loss and psychological disturbances than those with natural hair.
Keywords: African hair, hair care practices, psychological effects, scalp disorders
Alopecia (hair loss) was amongst the top-ten reasons for attending skin clinics in surveys of dermatology clinics in different parts of Nigeria and amongst African Americans.[1],[2],[3] Hair loss is associated with loss of self-confidence, low self-esteem and heightened self-consciousness.[4]
The African hair has a tendency to easy breakages along its length due to its curliness and dry texture, which gives it low tensile strength.[5],[6] Various techniques which have been developed to restructure and manage the hair include chemical relaxants, hot combing, hot iron curling and blow dryers. Other styling methods include the use of artificial weaves (sewed-in or glued-on artificial hair pieces to the existing natural hairs), corn rows, braiding of hairs with extensions, ponytails and various forms of hair-plaiting.[6],[7]
As a result of prolonged use of chemical combs and straighteners, and traction from different braiding methods, certain scalp problems designated 'disorders of hair care practice' have been documented across Africa and amongst African Americans.[7],[8],[9],[10] These include traction alopecia, chemical alopecia, pseudopelade of Brocq, Central Centrifugal Cicatricial alopecia (CCCA) and folliculitis decalvans.[7],[8],[9],[10]
Traction alopecia refers to traumatic hair loss resulting from the prolonged and repeated pull on hair follicles.[11] It was documented in 47% of young adult females between the ages of 12 and 35 years in secondary and tertiary institutions in Nigeria.[12] It is associated with persistent use of synthetic hair extensions, chemical hair relaxants, tight hairstyles such as braids, ponytails and plaits, attaching coloured and patterned beads at the tips of the braided hair, genetically inherent difficulty in combing the African hair and use of traditional head gears.[7],[8],[11] Traction alopecia is non-scarring and reversible in the early phase but becomes scarring in the late stages.[7],[8],[11] Clinical features of traction alopecia include scalp pain, erythema and tenting of the scalp in the acute phase and peripilar casts (sleeve-like keratinous structure encircling the hair shaft made of internal root sheath), traction folliculitis which may become secondarily infected and hair loss.[11]
Seborrhoeic dermatitis is a papulosquamous disorder that affects the sebum-rich areas of the body, such as the scalp, neck and trunk. In its mild form, scalp seborrhoeic dermatitis is itchy and scaly and colloquially called 'dandruff' in adults and 'cradle cap' in little children. It is common enough, affecting 15%–20% of the adult population worldwide.[13] A survey that looked at the hair and scalp disorder at a dermatology clinic revealed a low frequency of presentation. The physicians postulated this was a result of the low prevalence of severe forms of hair loss in women, a large number of over-the-counter anti-dandruff products and herbal remedies.[14],[15]
The objectives of this study were to determine hair care and grooming practices among women and to determine the relationship between hair care and grooming practices with hair loss and common scalp disorders (traction alopecia, chemical alopecia and seborrhoeic dermatitis). We also aimed to compare hair care practices and scalp disorders between individuals with natural hair and those with chemically relaxed hair. Finally, we sought to determine the psychological effects of hair care practices and scalp disorders in individuals with natural hair and those with chemically relaxed hair.
Subjects and MethodsThis was a descriptive, community-based survey done amongst women in Sagamu, a suburban town in Ogun State, Southwest Nigeria. Women living in Sagamu are an admixture of peasant farmers, market women, traders, teachers in public and private schools and those working in public institutions such as hospitals, banks and medium-to-large-scale industries. The survey was carried out at church functions and markets where many girls and women from various backgrounds congregated between July and December 2015. Prior verbal and written consent was obtained from the leadership of the churches and the markets and the women.
Sample size estimation was calculated using the formula for estimating a single proportion. The minimum number of participants to be studied was obtained from the formula N = Zα2 pq/d2 where N = minimum sample size, Zα =Standard normal deviate corresponding to a two-sided level of significance at 5% =1.96, P = prevalence of traction alopecia from previous community study on hair practices = 31.7%[10]q = 1-p, d = level of precision = 5%. Thus, N = (0.05 × 0.05) p (1-P)/(0/05) 2. This gave a minimum sample size of 332.7. Assuming a non-response rate of 10%, a minimum of patients 366 participants will be studied. This was however doubled to 732 to ensure a sizeable number of participants with relaxed and natural hairs are captured in the survey and increase the power of the study especially.
The instrument was developed at the Department of Medicine of the Lagos University Teaching Hospital and the College of Medicine of the University of Lagos. Approval was obtained from the Health Review and Ethics Committee of the Lagos University Teaching Hospital (HREC No ADM/DCST/HREC/APP/330).
The instrument is a questionnaire developed to document the hair grooming practices, complaints resulting from the grooming practices, psychological issues associated with hair loss problems and the presence of three common disorders of hair care which are traction alopecia, chemical alopecia and seborrhoeic dermatitis.[16],[17] Demographic data, which included age, occupation, educational background and ethnic and religious disposition, were obtained, and trained research assistants assisted the participants who were not literate to fill out the survey forms. The authors examined the scalps for seborrhoeic dermatitis (dandruff) and traction alopecia. All participants were also given leaflets on healthy hair care practices and preventive measures.
Data analysis was performed using SPSS Statistics for Windows, Version 22.0. IBM Corp., Armonk, NY. Data were represented with tables and figures, the mean, median, standard deviations (SDs) and percentages. The responses were compared between the natural hair and relaxed hair using the t-test for age and Chi-square or Fisher's exact test for all categorical variables. P < 0.05 was considered statistically significant for the various domains.
ResultsA total of 732 patients were screened. Five questionnaires were not analysed because respondents did not indicate hair care practice. Seven hundred and twenty-seven filled questionnaires were analysed. The mean age was 28.9 ± 11.4 (SD) and the range was 15 to 72 years. Most of the respondents (82.73%) were 40 years old and below. About 170 (23.38%) of the adults, particularly those with low educational levels, did not indicate their age. Respondents were predominantly Yoruba tribe (88.03%) and 425 (58.46%) had a minimum of tertiary education and were mostly Christians (81.43%) [Table 1].
There were 452 women (62.17%) with relaxed hair (chemically treated/straightened hair) and 275 women (37.83%) with natural (untreated) hair (ratio 2:1, P < 0.00001, χ2 = 85.2). Amongst respondents with relaxed hair (treated hair), 400 (55.02%) used chemical relaxers, 181 (24.89%) used chemical texturisers, 166 (22.83%) used hot combs, while others 4 (0.55%) used hair boosters and oils. Thirty-six (4.95%) respondents use hair dyes. The five-most common hairstyles were ponytails (66.71%), plaiting 58.46%, corn rows (Ghana weave) 45.2%, braiding/weaving 44.98% and twisting 38.24% [Table 2]. [Table 3]a and [Table 3]b shows the frequency and products used for hair washing. More respondents (33.15%) wash their hair monthly and 25.86% wash their hair every 2–3 weeks. Most respondents had long hair 660 (90.78%), which can be packed into a bun and managed with various hairstyles, while less than 10% had low cuts or short hairs, which are usually washed and combed.
The most reported symptoms/problems with hair care were hair loss in 39.61%, itching in 32.05% and flaking or scaling in 24.35% of the women. Women with relaxed hair experienced significantly more flaking of the scalp (P = 0.046, χ2 = 6.16), hair breakage (P = 0.023, χ2 = 11.35) and hair loss (P = 0.020, χ2 = 7.87) than those with natural hair [Table 4]. There was no statistically significant difference in symptom perception of pain and itching in both relaxed hair and natural African hair. Perceived causes of hair loss in respondents include hair care practices such as braiding of hair 123 (16.92%), retouching of hair 104 (14.31%), applying hair gels 27 (3.71%), use of hair extensions (attachments) in 20 (2.75%), weaving 12 (1.64%) as well as plaiting of hair 8 (1.10%), when due for retouching 6 (0.83%), aging 5 (0.69%), when left undone 5 (0.69%), twisting 4 (0.55%), tightness 4 (0.55%) and during harmattan weather 1 (0.14%). Only 10 (1.38%) of the respondents consult the dermatologist when they have scalp complaints. Most scalp complaints due to hair grooming practices were managed by respondents themselves 395 (54.33%); their hairdressers 281 (38.65%); with advice from friends and families 85 (11.69%); and with products advertised on TV, radio and internet and print media in 27 (3.71%).
Table 4: Reported problems with hair care practice within 3 months before data collectionThe most common psychological effects of hair scalp disorders were feeling of uneasiness 142 (19.5%), frustration 49 (6.7%), poor body image 40 (5.5%) and anger 38 (5.2%). However, more women with relaxed hair are significantly more affected psychologically by disorders of their scalp and hair (P = 0.0008, χ2 = 7.043). There was no statistically significant difference in the perception of hair as being healthy in the two groups of women.
On examination of the scalp, seborrhoeic dermatitis (SD) evidenced by scaling/flaking of the scalp was observed in 230 women (31.6%), diffuse hair loss in 438 (60.3%), while traction alopecia was noted in 433 (59.6%) of women. Overall, there was no statistically significant difference in the prevalence of SD (P = 0.56, χ2 = 1.16) and traction alopecia (P = 0.23, χ2 = 2.89) in individuals with relaxed hair and natural hair. However, significantly more women with relaxed hair experienced moderate hair loss from traction than women with natural hair (P = 0.014, χ2 = 8.52).
DiscussionThere is an observed trend that many people of African descent are changing from chemically and thermally treated hairstyles to natural (non-chemically treated or relaxed) hairstyles.[16] This is not unconnected to the documented disorders associated with these hair care practices, such as chemical alopecia and CCCA.[17] F, the use of relaxers has been implicated in uterine leiomyomata and breast cancers in studies in Ghana and African Americans.[18],[19],[20] This study noted significantly more women of all age groups having chemically relaxed hair than natural hairstyles, approximately a ratio of 2:1 (P < 0.00001, χ2 = 85.2). Similarly, Okoro et al., in North Central Nigeria, noted the use of chemical relaxers in 68.8% of girls in a secondary school and Khumalo et al. in 75.7% of women in a community study in Capetown, South Africa.[10],[21] A study done amongst women of African descent in London, UK, revealed that more women, 52.6% had natural (untreated) hair than relaxed hair.[22] This is a trend that has begun to gain some traction in Western countries, probably because of a reawakening of social/cultural identity in these women.
Some reasons given for the use of chemical relaxers in Nigerian women include the notion that chemically straightened or relaxed hair is more beautiful, socially acceptable, convenient, easy to manage and improves self-esteem, while natural untreated hair is tougher.[23] While the use of relaxers has been associated with the era of the slave trade and the tendency to be 'Eurocentric', the use of hair straighteners has been adduced to the pre-slave trade era.[24],[25] In general, women of African descent have been noted to spend a lot of time and resources on their hair and the trend to natural hair amongst African Americans is associated with a desire for identity and has political connotations.[25],[26]
In this study, it was seen that irrespective of whether the hair is natural (untreated) or relaxed (treated), the most common hairstyles were ponytails (packing), plaiting, Ghana weave (cornrows), braiding/weaving and African weave ('didi'/matting). Women with natural hair practiced African weaves significantly more than those with relaxed hair, while there was no significant difference in the plaiting of hair in the natural and the relaxed hair. Hairstyles such as ponytails (packing in a bun), plaiting, Ghana weave (cornrows), braiding/weaving, Multiple single braids (“Bob Marley”), gelling and extensions were seen more in those with relaxed hair than the natural hair. It is worthy of note that styling of relaxed (treated) hair was not common in the women in this study. This may be because the study was done in a suburban town not as Eurocentric as the more Westernised commercial capital of Nigeria-Lagos. Many of the participants in this study are Christians and may be less inclined to apply chemical relaxants to their hairs due to some religious teachings which frown on such 'worldly' practices. Our study supports the findings of Majali et al. in South Africa on the tendency for African women to move between traditional African hairstyles such as weaving, plaiting and braiding and the Western styles of straightening/relaxing and the use of extensions.[25]
Natural curly African hair is genetically weaker than straight Caucasian hair because of the curliness of the lower half of the hair shaft, less moisture/dryness of the hair with a tendency to increased physical trauma from high fragility and increased variability of the hair shaft. Furthermore, various hair care practices further predispose African hair to breakages.[27],[28],[29] The relaxers and straighteners reduce the tensile strength of the hair by distortion and rearrangement of the disulfide bonds of the shaft. The thermal straighteners, which include hot combs and curling tongs, cause the weakening of the disulfide bonds, while the chemical straighteners cause permanent straightening of the hair by the destruction of the bonds and replacement of the cystine by lanthionine and formation of new bonds.[27],[28],[29],[30] This study shows chemical relaxants as the most common methods for straightening the hair in these participants. Others use chemical texturisers, hot combs, hair boosters and oils.
Various hair care practices such as twists, braids, weaves and plaiting of the hair are also associated with the weakening of the hair at the points of attaching to the scalp. Given the long duration of these hairstyles, they are infrequently washed and combed; hence, they become dry, tangled and break easily.
The most reported symptoms/problems with hair care were hair loss, itching and flaking or scaling of the scalp, similar to reports by other studies.[10],[21],[22],[23] Women with relaxed hair experienced significantly more flaking of the scalp, hair breakage and hair loss than those with natural hair within 3 months before the study [Table 5]. For the participants with relaxed hair, there are multiple insults on the hair and scalp from the inherent weakness and dryness of the African curly hair, the increased hair fragility caused by the hair straighteners and texturisers, as well as the physical trauma and traction caused by various indigenous hairstyles such as twists, braids, ponytails, cornrows, plaiting and extensions done by individuals of African descents.[16],[31],[32] The choice of these hairstyles includes social media trends, fashions, cultural acceptability, Eurocentric standards of beauty and professionalism, neatness, reduced need to comb and ease of management of the hair.[31],[33]
One month duration between hair wash cycles was the most reported in this study. The study also found that there were more hair problems or complications with longer duration of hair wash cycles, while those with shorter intervals between hair washing had fewer hair problems or complaints [Figure 1]. Various reasons have been alluded to for the infrequent washing of hair in Africans when compared to their Western counterparts ranging from difficulty in managing their natural hair to time constraints and cost consumption.[23],[25],[26] The frequency of hair washing is prolonged as expected because of the braiding and weaving of hair from 17.9 days to 32.8 days in a cohort of Africans studied.[22]
Figure 1: Relationship between frequency of hair washing and scalp symptomsOther potential causes of hair loss and scalp disorders include infrequent hair washing, use of wrong shampoos and conditioners, poor moisturising of the scalp leading to excessive dryness on the background of genetically fragile hair type, and hair care practices that predispose to hair loss. The study noted that most participants use regular shampoos and hair conditioning shampoos. Individuals with natural hair use regular toilet bar soaps to wash their hair significantly more than those with treated hair which further predisposes the hair to damage. This is likely because of the friction created by using the bar soaps on the hairs directly, as well as the fact that bar soaps are conventionally more drying than shampoos with a higher alkaline content in the pH range of 9-10 compared with the pH of 6-7 in shampoos.[34] Thus, though this study found that with reduced frequency of hair washing, there were more scalp symptoms and hair loss in most respondents, it is noted that washing the hair, although frequently with bar soaps, was also associated with hair loss. Shampoos are more gentle and healthier on the hair and scalp than bar soaps.
Hair and scalp shampoos contain detergents made of lauryl sulphate soaps for the removal of dirt, oils, conditioners, foaming agents, fragrances, preservatives, opacifiers and sequestrating agents. Different types of shampoos can be used depending on the hair type, health needs of the hair and scalp, presence of hair loss, scales and excessive sebum. These include regular shampoo, dry hair, damaged, oily hair, deep cleaning, baby, medicated, two-in-one and hair dyeing shampoos.[35],[36],[37] It is ideal that African hair types should use shampoos with fewer detergents, more conditioners, and moisturising oils such as coconut and sunflower oils. Regular and judicious moisturising of the hair and scalp has been noted to strengthen African hair and reduce breakages. Coconut oil, amongst vegetable oils, is the most useful.[38],[39],[40],[41]
Traction alopecia [Figure 2] is a commonly documented complication of hair care practices in community studies across all age groups in Africans.[10],[12],[21],[42] There appears to be an underreporting of traction alopecia and diffuse hair loss generally amongst the participants. Just over 14% of participants self-reported receding hairline from traction with the fringe sign and 39.6% reported diffuse hair loss, while on examination, 59.6% of participants had traction alopecia and 60.3% had features of diffuse hair loss [Table 4]. Okoro reported 80% of traction alopecia in a secondary school cohort.[21] The high rate is not unexpected given the large number of people with chemically relaxed hair simultaneously practicing hairstyles that put pressure on the hairline. The underreporting suggests that the women may perceive the mild cases as normal, especially as it is seen in most people.
Figure 2: Traction Alopecia with fringe sign (blue arrow) at the frontal margin of scalpApart from hair loss, this study reported features suggestive of seborrhoeic dermatitis as evidenced by itching and flaking of the scalp in 31.6% of respondents. Irritant contact dermatitis and allergic contact dermatitis to various products of hair grooming practices, including hair extensions, have also been reported.[7],[43]
Studies from the skin clinic showed fewer women presented to the clinic with hair disorders from hair care practices compared to greater than 60% seen in this community survey.[7],[14] This is not unrelated to the fact that many women treat themselves or are treated by hairdressers and only see the dermatologist with severe symptoms, as indicated by the respondents. There is a great need to actively engage in medical education to translate the scientific knowledge of hair care practices as a direct cause of hair and scalp disorders such as traction alopecia and seborrhoeic dermatitis amongst others. This education will be useful to women in general and hairdressers. Information such as: not tolerating pain from hairstyles, desisting from frequent braiding or weaving newly relaxed hair, encouraging frequent shampooing which promotes water content to the hair and scalp, promoting the use of moisturising or conditioning shampoos for the different hair types and nurturing the curly African hair will be of great public health interests.[35],[37],[44]
While close to 60% of respondents felt indifferent and not bothered by their hairstyles and hair and scalp disorders, 40.7% of respondents had various psychological disturbances ranging from a feeling of uneasiness, frustration, dissatisfaction about the way they look, anger, sadness and embarrassed to depression [Table 6]. Participants with relaxed hair appear to have more physical symptoms, hair loss and psychological disturbances than those with natural African hair. Hair care practices and hair/scalp disorders have been shown to bring African women a sense of identity, Africanism, sense of status and placement and self-esteem.[25],[45],[46] A limitation of this study was the lack of scalp biopsy or trichoscopy to verify some diagnoses, although made by dermatologists. A large number of participants precluded the action.
Table 6: Psychological effects of hair care practices and scalp disorders on respondents Conclusion This study showed that Nigerian women experienced clinical and psychological distress consequent to their hair care and grooming practices. Individuals with relaxed hair have more physical symptoms, hair loss and psychological disturbances than those with natural African hair. There is a need for the development of hair care and grooming techniques with minimal or no adverse effects.
Acknowledgement
The abstract of this article was first published by Elsevier® as ”Hair care practices, scalp disorders and psychological effects on women in Nigeria” by Ayanlowo OO, Otrofanowei E, in the Book of Abstracts of Journal of the American Academy of Dermatology 2019 volume 81, Issue 4, AB218, October 01, 219. DOI: https://doi. org/10.1016/j.jaad. 2019.06.799.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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