A process evaluation of a cluster randomised trial hosted in hairdressing salons promoting women's cardiovascular prevention

This process evaluation of the "Hairdressers for Health" cluster randomised trial found that while using hairdressing salons to promote cardiovascular health checks for women was acceptable and leveraged trusted hairdresser-client relationships, the study faced significant challenges in salon recruitment and participant adoption due to technological constraints and privacy concerns.

The Gist

Imagine you want to get a group of people to go to the doctor for a heart check-up. Usually, you'd try to do this through hospitals or clinics. But what if you tried to do it somewhere people already feel comfortable, relaxed, and chatty? Like a hair salon?

That is exactly what this research team tried to do. They ran a big experiment called "Hairdressers for Health." Here is the story of what happened, explained simply.

The Big Idea: The "Hair Salon as a Health Hub"

The researchers knew that heart disease is a silent killer, especially for women over 45. They also knew that many women visit hairdressers regularly. In fact, over half of Australian women over 50 get their hair done every month.

The Analogy: Think of a hair salon like a "community living room." It's a place where women gather, relax, and chat about everything from their kids to their health. The researchers thought, "Why not use this trusted space to nudge women toward better heart health?"

The Experiment: The "Nudge"

They set up a trial in 120 salons across New South Wales.

• The Plan: They gave hairdressers flyers and posters. When a woman sat in the chair, the hairdresser would gently suggest, "Hey, have you had your heart health check lately? Here's a flyer with a QR code to learn more."
• The Goal: To see if this simple "nudge" would get women to book an appointment with their doctor (GP) for a free heart check-up.

What Went Right? (The Successes)

1. The Setting Worked: The hair salons were a great place to talk about health. Women felt safe and comfortable there. One hairdresser said it felt natural because they were already chatting about "women's health" and "when was your last doctor visit" anyway.
2. The Relationships Mattered: In smaller salons where the hairdresser knew the clients personally, the "nudge" worked much better. It's like if your best friend tells you to eat an apple, you're more likely to listen than if a stranger hands you one.
3. The Idea Was Popular: Both the hairdressers and the women liked the idea. They felt it was a clever way to look out for each other.

What Went Wrong? (The Hiccups)

Even though the idea was good, the execution hit some speed bumps.

• The "Tech Wall": The study asked women to scan a QR code with their phones and fill out a long form online.
  • The Metaphor: Imagine trying to build a house, but the bricks are made of glass. It looks nice, but it's fragile and hard to handle. For some women, scanning a code and typing in personal details felt scary or too complicated. They worried about privacy or just didn't have good internet in the salon.
• The "Busy Hairdresser" Problem: Hairdressers are incredibly busy. They are cutting hair, chatting, and managing the shop.
  • The Metaphor: Asking a hairdresser to remember to hand out flyers is like asking a chef to remember to water the plants while they are cooking a five-course meal. Sometimes, the flyers just got forgotten or left in a drawer.
• The "Ghost" Follow-up: Once a woman signed up, the researchers didn't talk to her much again. They sent a text or email, but that's it.
  • The Result: Many women signed up but never actually went to the doctor. It's like buying a gym membership and never going because no one called to remind you.

The Numbers Game

• They hoped to get 120 salons involved. They got 116. Good start!
• But, only 54 of those salons actually managed to get any women to sign up.
• In total, only 239 women joined the study out of the thousands who walked through those doors.
• Of those 239, about two-thirds finished the first survey, but only about 60% finished the check-up six months later.

The Big Lesson: Trust is the Key

The researchers realized that while technology (QR codes and emails) is fast and cheap, it's not always the most human way to do things.

The Takeaway:
If you want to change people's health habits, you can't just drop a flyer on a table and hope for the best. You need to lean on trust.

• In the future, if you want to use hair salons for health, you need to train the hairdressers better so they feel confident talking about it.
• You need to make the sign-up process easier (maybe less personal data required).
• Most importantly, you need to keep the conversation going. A one-time "nudge" isn't enough; you need a gentle, ongoing reminder.

In a Nutshell

The study proved that hair salons are a great place to talk about heart health, but the researchers tried to do it too much like a computer program and not enough like a human conversation. To make it work next time, they need to treat the hairdressers like partners, not just mailboxes, and make the process feel as warm and welcoming as a visit to the salon itself.

Technical Summary

1. Problem Statement

Cardiovascular (CV) disease remains a leading cause of death globally and specifically affects Australian women significantly, with high rates of uncontrolled risk factors (e.g., hypertension, dyslipidaemia, obesity) among women over 45. Despite the availability of a government-funded "Heart Health Check" (HHC) via the Medicare Benefits Schedule (MBS) for women aged 45+, uptake is critically low (only 1.1% of eligible women in NSW accessed it in 2020).

The study addresses the challenge of reaching women in non-traditional healthcare settings. While community-based interventions (e.g., barber shops) have shown promise, there is a need to evaluate the feasibility, acceptability, and barriers of using hairdressing salons as a novel site for CV risk assessment promotion, specifically leveraging the high frequency of salon visits by women (52% of women ≥50 visit a salon within a 4-week period).

2. Methodology

The study employed a process evaluation nested within a pragmatic cluster randomised trial ("Hairdressers for Health") conducted in New South Wales, Australia.

• Study Design:

  • Setting: 120 hairdressing salons (88 metropolitan, 28 regional) were recruited.
  • Randomisation: Salons were randomised 1:1 to Intervention or Control arms.
  • Intervention (Nudge): Women ≥45 years were advised via flyers/QR codes to undertake a HHC with their GP. They received a CV-specific pamphlet and a letter for their GP.
  • Control: Women received a general women's health pamphlet only.
  • Blinding: Salons and researchers were blinded to allocation.
  • Data Collection: Decentralised, online recruitment via QR codes scanning to a bespoke electronic platform. Primary outcomes were assessed via linkage to MBS and Pharmaceutical Benefits Scheme (PBS) data at 6 months.

• Process Evaluation Framework:

  • Guided by the UK Medical Research Council (MRC) framework and the Implementation Research Logic Model.
  • Qualitative Data: 19 semi-structured interviews conducted post-trial (9 hairdressers, 9 participants, 1 project officer) using grounded theory and thematic analysis.
  • Quantitative Data: Descriptive statistics of salon characteristics (SEIFA scores, location) and participant demographics (age, education, recruitment rates).
  • Analysis: Thematic coding (inductive) using NVivo 11.0; descriptive statistics via Excel and Power BI.

3. Key Contributions

• Novel Setting Validation: Confirms that hairdressing salons are an acceptable and appropriate setting for delivering cardiovascular health messaging to women, capitalising on the "cone of silence" and trust inherent in the hairdresser-client relationship.
• Implementation Insights: Provides a granular analysis of the barriers and facilitators specific to decentralised, non-healthcare pragmatic trials, highlighting the tension between low-resource "nudge" designs and the need for active engagement.
• Recruitment Strategy Comparison: Demonstrates the critical difference between passive recruitment (relying on industry councils) and active recruitment (face-to-face visits), showing that the latter is essential for research-naive community settings.
• Privacy vs. Participation: Identifies that requiring personal identifiable information (PII) for online consent in a community setting acts as a significant barrier to recruitment, a finding crucial for future e-health trial designs.

4. Key Results

• Recruitment & Reach:

  • Salon Recruitment: 116 salons were enrolled (target 120), but only 54 (47%) actively recruited participants.
  • Participant Recruitment: A total of 239 participants were recruited (range 1–22 per salon).
  • Recruitment Speed: Initial passive recruitment was slow; switching to active face-to-face recruitment significantly accelerated salon participation.
  • Completion: 96% completed the baseline questionnaire; 63% completed the 6-month follow-up.

• Barriers Identified:

  • Technological Constraints: Poor internet connectivity in salons and participant aversion to QR codes/online forms.
  • Privacy Concerns: Participants were hesitant to enter personal data (e.g., Medicare numbers) on public devices or online platforms.
  • Workflow & Memory: Hairdressers frequently forgot to distribute materials due to busy schedules and lack of reminders.
  • Blinding Limitations: The blinded design prevented hairdressers from understanding the study's specific goals, reducing their ability to advocate for the intervention.
  • Lack of Follow-up: The "nudge" design lacked sufficient post-sign-up reinforcement, leading to low conversion from sign-up to actual GP visits.

• Facilitators Identified:

  • Trusted Relationships: Established hairdresser-client relationships were the primary driver of participation, particularly in smaller, regional salons with regular clientele.
  • Acceptability: Both staff and clients viewed the salon as a comfortable environment for discussing health topics.
  • Personal Motivation: Hairdressers with personal health histories were more motivated to engage clients.

• Quantitative Disparities:

  • Control salons had more "high recruiters" (>10 participants) than intervention salons (6 vs. 2).
  • Regional salons generally showed higher recruitment rates per salon compared to metropolitan ones, likely due to tighter community bonds.

5. Significance and Conclusions

The study concludes that while hairdressing salons are a feasible and acceptable venue for cardiovascular prevention messaging, the implementation strategy must be carefully tailored to the non-healthcare context.

• Design Implications: Future pragmatic trials in community settings should move away from purely passive, decentralised recruitment if high reach is required. Active recruitment and personalised engagement are necessary.
• Relationship Leverage: The study suggests that blinding the intervention in such settings may be counterproductive. Future designs should consider unblinded or semi-blinded approaches that allow staff to understand and champion the intervention, leveraging their trusted status.
• Data Collection: To improve retention and reduce privacy barriers, future studies should consider minimising the collection of PII during the initial "nudge" phase or providing alternative, low-tech consent methods.
• Policy: The findings support the potential of non-clinical settings for public health interventions but highlight that "low-cost" designs often incur hidden costs in terms of recruitment efficiency and data quality if stakeholder relationships are not actively managed.

In summary, the "Hairdressers for Health" trial demonstrates that while the concept of using salons for CV prevention is sound, the execution requires a balance between pragmatic minimalism and the active cultivation of trust and relationships within the community setting.