Journal of Community Health

https://doi.org/10.1007/s10900-020-00792-1

ORIGINAL PAPER

Health Promotion Awareness in Barbershops and Salons:

An International Cross‑Sectional Survey in Japan and Thailand
Sachiko Makabe1   · Yu Kume2   · Tomohiro Kamata3 · Hataichanok Apikomonkon4 · Jiranan Griffiths4 ·
Junko Takagai1 · Yuko Akagawa1 · Hideaki Andoh1 · Tomoko Ito1 · Naruemol Singha‑dong5

© Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Aging societies are a worldwide concern, as people are living longer than ever before. The success of the “barbershop
project” in improving community health in the USA suggests that the aging issue can be tackled using this method even in
Asia. Nevertheless, the health promotion awareness of barbers/stylists has barely been reported in Asia. This study aimed
to identify the health promotion awareness of barbers and stylists in Japan and Thailand. An international cross-sectional
survey was conducted between March and December 2017. Questionnaire contents included the “current status of existing
health-promotion-related services,” “awareness of contribution to maintaining people’s health,” and “awareness of col-
laboration with health care professionals.” Participants were 99 Japanese and 101 Thai shop owners. In Japan, more health-
promotion-related services were already provided through shops, and health care awareness was higher than in Thailand.
In both countries, some shops were willing to collaborate with health care professionals. In Japan, “barbers/stylists have
consultation opportunities with health care professionals,” “health-related leaflets are provided,” “development of therapy/
care,” and “barbershops/salons become a bridge between communities and hospitals” were mentioned as ideas for collabora-
tion. In conclusion, barbers/stylists are highly interested in health due to the direct connection between beauty and health.
Collaboration between barbershops/salons and health care professionals is possible, especially in Japan due to its super-aging
society. Further development of the barbershop/salon project is needed.

Keywords  Health promotion awareness · Barbershops · Salons · Aging society · Asia

Introduction the percentage of older people (over 65 years old) in the

Aging societies are a worldwide concern, and people are
living longer than ever before. Japan leads this trend due to
its prolonged life expectancy and depopulation. In Japan,
* Sachiko Makabe
1smakabe@gipc.akita‑u.ac.jp
1
Department of Clinical Nursing, Akita University Graduate
School of Health Sciences, 1‑1‑1 Hondo, Akita 010‑8543,
Japan
2
Department of Occupational Therapy, Akita University
Graduate School of Health Sciences, Akita, Japan
3
TRAPE Corporation, Osaka, Japan
4
Department of Occupational Therapy, Faculty of Associated
Medical Sciences, Chiang Mai University, Chiang Mai,
Thailand
5
Institute of Nursing, Suranaree University of Technology,
Nakhon Ratchasima, Thailand
total population is predicted to reach 30% in 2025 [1]. Cur-
rent governmental systems and social institutions will not
be able to cope with this super-aging society, and thus a
new social system needs to be developed to ensure people’s
successful aging. Meanwhile, in Thailand, the percentage
of older people (over 60 years old) will hit 16% in 2025 and
is expected to continue to increase rapidly thereafter [1];
while the percentage of older people is lower in Thailand,
the growth rate is faster than in Japan. The Thai Ministry of
Public Health accordingly strongly focuses on care service
development for older people [2]. Therefore, although Japan
and Thailand are quite different, the aging issue is similar
in both countries, and international collaborative research
should adopt innovative viewpoints from which to identify
the strengths and challenges of both nations.
Barbers/stylists are health educators who do more than
just cut hair [3]. Barbers hold people’s trust due to their
historical background of performing surgery in ancient

13
Vol.:(0123456789)

times; historically, surgeons originated from barbers. In
ancient Europe, people called barber surgeons to conduct
surgery [4]. Currently, barbershops and salons are scattered
throughout communities, and people visit them regularly. By
using these occupational-nature-related strengths, barbers
could help monitor health and provide relevant information
to people to improve community health. There is a well-
known barbershop project for community health improve-
ment conducted by Dr. Joseph in the USA [5, 6]. In this
project, barbers were trained to give educational interven-
tions regarding prostate cancer to African American men
who dislike visiting hospitals, thereby raising prostate can-
cer awareness among a priority population. Numerous other
positive reports have been made of barbershop/salon health
interventions, especially in the USA in the areas of hyperten-
sion, skin disease, kidney disease, dementia, sexual health
education, eating habit improvement, and physical activity
improvement [7–15]. Circumstances differ between the USA
and countries in Asia, but the barbershop/salon approach
might be adopted in Asia. Nevertheless, the health promo-
tion awareness of barbers/stylists in Asia has barely been
reported.
Our research team observed and interviewed barbers/
stylists in Japan and Thailand between June and August
2016 [16]. Through this pilot study, we identified important
similarities and differences between the two countries. The
similarities are that barbers/stylists already have a health
promotion mindset and wish to improve people’s health
due to the strong connection between beauty and health.
The differences are that Japan is more advanced in offering
health-promotion-related services like daily life advice or
relaxation therapy due to its super-aging society. Conversely,
in Thailand, health care professionals are good at utilizing
existing community resources due to the limited resources/
finances compared to that in Japan. However, this is a small
dataset from a very limited set of observations. A more con-
solidated survey is needed.
To understand the health promotion awareness of barbers/
stylists in Japan and Thailand, this study aimed to identify
through an international cross-sectional survey (1) the kinds
of health-promotion-related service already provided, (2)
whether barbershop/salon can contribute to maintaining
people’s health in an aging society, and (3) whether barbers/
stylists wish to collaborate with health care professionals.
Methods
Participants and Procedure
The total sample size was set at 200 shops, divided into 100
shops in each country. In each country, 45 barbershops, 45
salons, and 10 mixed shops (barber and stylist dual-license
13
Journal of Community Health
holders) were divided for an ideal sample proportion to gain
a comprehensive overview reflecting the standard proportion
of shops and to ensure adequate comparisons. The inclusion
criteria were (1) a shop owner, (2) any sex, and (3) any age.
There were no exclusion criteria.
The study design was an international collaborative
cross-sectional questionnaire survey. The survey period
was between March and December 2017. The locations were
Akita Prefecture, which has the highest aging population in
Japan, and Chai Mai and Nakhon Ratchasima provinces in
Thailand, where our research team had already been col-
laborating on aging society research.
For the recruitment method [3], in Japan, questionnaires
were posted to shops selected randomly from a registration
list until we reached an adequate sample size; answered
questionnaires were posted directly to a research leader. In
Thailand, we selected shops randomly in each province from
a registration list and gave/collected questionnaires to/from
the shop owners directly. This process was continued until
we reached an adequate sample size. The method used in
Thailand was selected because of the higher illiteracy rate
in Thailand than in Japan. In both countries, a pen was given
to the participants as a reward.
Questionnaire Contents
To develop the questionnaire contents, in addition to con-
ducting an extensive literature review on the barbershops/
salons community health promotion project [17–19], the
Japanese and Thai researchers visited and observed barbers/
salons in each country in order to understand their occupa-
tional circumstances.
Demographic data included the type of shop (barbershop,
salon, or mixed), staff number, sex, age, years of education,
and hospitalization experience. Hospitalization experience
of owners was included because such experiences might lead
to higher health promotion awareness.
To understand the current status of existing health-pro-
motion-related services, the following topics were covered
with responses of “yes” or “no.” The counseling aspect
included “listening to health problems,” “giving advice on
daily life,” and “giving advice on going to the hospital.”
The therapeutic aspect included “providing relaxation” and
“providing massages.” The environmental aspect included
“providing a place for community gatherings” and “provid-
ing a service depending on physical condition.”
To measure their awareness of their contribution to main-
taining people’s health, we asked, “In an aging society, do
you think that barbers/stylists can contribute to maintaining
people’s health?” Responses included “very much,” “much,”
“neither,” “hardly any,” and “not at all” (five levels), fol-
lowed by an open-ended comment on their reasons.
Journal of Community Health
Finally, to identify their awareness of collaboration with
health care professionals, we asked, “Do you think that it is
a good idea to collaborate with health care professionals?”
Responses included “very much,” “much,” “neither,” “hardly
any,” and “not at all” (five levels), followed by an open-ended
comment on their reasons.
Data Analysis
Demographic data on each country were descriptively ana-
lyzed and compared using a Mann–Whitney U test for staff
number, age, and years of education, and a chi-square test for
type of shop, sex, and hospitalization experience.
Current health-promotion-related services were compared
between countries using a chi-square test. For contribution
awareness and collaboration awareness, the proportions of the
responses (very much, etc.) were compared between coun-
tries using chi-square test. The responses were combined into
three levels (“very much and much,” “neither,” and “hardly
any and not at all”) for analysis to avoid statistical errors as
the proportions were zero within some cells when five lev-
els (“very much,” “much,” “neither,” “hardly any,” and “not
at all”) were used. A qualitative analysis was then conducted
on the open-ended comments. Two researchers, including the
lead researcher, conducted analyses independently, and then
discussed the results to reach a consensus. This method was
used to ensure trustworthiness and to improve the qualitative
analysis [20].
Ethical Considerations
The led university in Japan (registration number 1635 by
Akita University) ethically approved the study protocol first.
Then each organization in Thailand received ethical approvals
(registration number 307/2560 by the Faculty of Associated
Medical Sciences, Chiang Mai University, and registration
number 36/2560 by Suranaree University of Technology). It
was also registered trial at UMIN in Japan (registration number
UMIN000026106).
Participants received a letter reporting the study aims and
methods, which included the following: (1) notice that their
privacy was strictly protected; (2) notice that participation was
voluntary; (3) notice that the data would be presented only
in aggregate form in professional journals; (4) as a disadvan-
tage, time spent responding to the questionnaires. Returning
the questionnaire was regarded as consent to participate in
the study.
Results
Table 1 lists the characteristics of participants. In total, 99 Jap-
anese (11% response rate) and 101 Thai (82% response rate)
shop owners (200 in total) participated. The proportion of shop
types was identical in both countries. Barbers constituted over
40%, stylists over 40%, and mixed (dual licenses) about 10%.
The distribution of staff numbers was also largely identical,
with the majority having one or two staff members, including
the owner, per shop. The sex ratio was approximately 50/50
and not significantly different between the countries. By age,
49% of Japanese participants were over 60 years old, com-
pared with 5% in Thailand, which was a significant differ-
ence (p < 0.05). The years of education (mean ± SD) in Japan
(12 ± 0) were significantly higher (p < 0.05) than in Thailand
(9 ± 1). For hospitalization experience of the owner, there were
no significant differences between countries, though the level
was slightly higher in Japan (42%) than in Thailand (33%).
Figure 1 shows the current status of existing health-promo-
tion-related services. In Japan, commonly provided services
not common in Thailand were “Listening to health problems”
(69%), “Advice on going to the hospital” (61%), “Providing
relaxation” (76%), “Providing massages” (80%), and “Provid-
ing services depending on physical condition” (77%). In Thai-
land, a commonly provided service not common in Japan was
“Providing a place for community gatherings” (40%). Finally,
the provision of “Advice on daily life” did not significantly
differ between countries.
Figure 2 shows the awareness of contributions to maintain-
ing people’s health in an aging society. Japan (71%) exhibited
significantly higher awareness than Thailand (49%) (p < 0.01).
Among contributions extracted from the open-ended com-
ments, “Consultations about health” was found in both coun-
tries. In Japan, “Mental support,” “Noticing changes in health
condition due to regular visits,” “Providing health checks,”
and “Providing a place for community gatherings” were
mentioned.
Figure 3 shows awareness of collaborations with health care
professionals. There were no significant differences between
Japan (49%) and Thailand (43%). For collaboration contents
as extracted from the open-ended comments, “Health educa-
tion for barbers/stylists” was found in both countries. In Japan,
“Barbers/stylists have consultation opportunities with health
care professionals,” “Leaflets about health are provided,”
“Development of therapy/care,” and “Barbershops/salons
serve as a bridge between communities and hospitals” were
mentioned.
13
 Journal of Community Health

Table 1  Characteristics of Contents Japan (n = 99) Thailand (n = 101) p value

participants (N = 200)
Number (%) Mean ± SD Number (%) Mean ± SD

Shop information
 Type p = 0.87
  Barbers 45 (46) 47 (46)
  Stylists 41 (42) 44 (44)
  Mixed 12 (12) 10 (10)
 Staff numbers including owner p > 0.05*
  Less than 1 48 (49) 58 (59)
  More than 2 49 (51) 3 ± 4 41 (41) 2 ± 2
Owner information
 Sex p = 0.89
  Male 44 (44) 43 (43)
  Female 55 (56) 58 (57)
 Age 59 ± 14 45 ± 11 p < 0.05*
  20 s 1 (1) 12 (12)
  30 s 10 (10) 17 (17)
  40 s 13 (13) 38 (37)
  50 s 26 (27) 29 (29)
  More than 60 s 48 (49) 5 (5)
 Year of education 12 ± 0 9 ± 1 p < 0.05*
 Hospitalization experience p = 0.24
  Yes 41 (42) 33 (33)
  No 57 (58) 67 (67)

Missing value exist in some data

*
 p < 0.05

Fig. 1  Current status of existed Consulta on aspect

health-promotion-related ser- Japan
vices (n = 200) Listen to health problems **
Thailand
Advice on daily life Japan
Thailand
Japan
Advice on going to the hospital **
Thailand

Therapeu c aspect
Japan
Provide relaxa on **
Thailand
Japan
Provide massages **
Thailand
Environmental aspect
Provide a place for Japan
community gatherings Thailand **
Japan
Provide services depends on **
physical condi on Thailand
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

:YES :NO *p < 0.05, **p <0.01

13
Journal of Community Health

Fig. 2  Awareness of contribu-
Queson
tions to maintain people’s health
(n = 194) In an aging society, do Japan
you think that
barbers/stylists can **
contribute to
maintaining people’s Thailand
health?
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

:Very much and much :Neither : Hardly any and not at all *p < 0.05, **p <0.01

What Kind of contribuon (free comments)

From Japan From Thailand

• Consultaons about health • Consultaons about health

• Mental support
• Nocing changes in Health condion due
to regular visits
• Providing Health checks
• Provide a place for community gatherings

Fig. 3  Awareness of collabora-
tions with health care profes- Queson
sionals (n = 195) Japan
Do you think that it is
good idea to collaborate
with health care
professionals? Thailand
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

:Very much and much :Neither : Hardly any and not at all Not significant

What Kind of collaboraon (free comments)

From Japan From Thailand

• Health educaon for barbers/stylists • Health educaon for barbers/stylists

• barbers/stylists have consultaon
opportunies with health care
professionals
• leaflets about health are provided
• Development of therapy/care
• Barbershops/salons serve as a bridge
between communies and hospitals

Discussion higher in Japan than in Thailand. In both countries,

In Japan and Thailand, an international collaborative sur-
vey was conducted to identify the health promotion aware-
ness of barbers/stylists. Demographically, most of the
shops showed an even sex ratio and only a few staff mem-
bers. Japanese respondents were significantly older and
more educated than Thai ones. In Japan, barbers/stylists
were already providing health-promotion-related services
to customers due to their super-aging social background.
The health contribution awareness was also significantly
some shops were willing to collaborate with health care
professionals.
Barbers/stylists are recognized as health educators and
have the trust of people in the community [3, 7]. These
study results are comparable to those of recent studies.
Barbers/stylists strongly believe that beauty comes from
a healthy physical state. Some barbers even wear a white
uniform, which reminds people of health care profession-
als [4]; thus, people feel comfortable talking with them
about health issues. Barbers/stylists tend to have good
communication skills and wide access to information, so

13

their shops can serve as information exchange platforms
for community health promotion. Although community
settings vary in terms of kiosks or religious places such as
churches [21, 22], barbershops or salons are ideal places
for future health promotion outreach in Asia, not just in the
USA. In addition, due to its younger population, maternal
and child health as well as hygiene control can be focused
on in Thailand; thus, the shops that participate in this type
of health care collaboration need to be run by nationally
licensed or educationally standardized barbers/stylists.
A future barbershop/salon project for health promotion
in Asia will contribute a new social institution. Innova-
tions and new value occur when people from heterogene-
ous backgrounds collaborate [23, 24]. This study included
different specialties, such as barbers/stylists and health
care professionals, and an international collaborative
observation clarified the weaknesses and strengths of the
two countries. Japan has lost a sense of barbershops as
community places, whereas Thailand showed respectable
community utilization. Further, Japan is facing a situation
of advanced aging; consequently, Thailand can introduce
a preventive pathway by learning from Japan. In addition,
the finding on the high hospitalization rate, in light of the
younger population in Thailand, indicates that the Japa-
nese health environment is more advanced.
The challenge is in implementing a barbershop/salon
project involving collaboration with the health care sector.
Not every owner was interested in this idea [9]. Contribu-
tors need to be carefully selected to achieve effective out-
comes. On the other hand, national and local barbershop/
stylist associations exist in both countries, so the already
existing networks could be used to expand and systematize
the project. Moreover, the workload is high at barbershops/
salons, and taking on a new role would further increase the
workload. Hence, new systems/resources need to be devel-
oped to operate the project and assist with workload man-
agement. Finally, reductions in barbers/stylists’ income
as a result of collaborating with health care profession-
als would not be beneficial. If a health promotion project
added new value and was funded, then it could operate
continuously and expand.
This study had several limitations. First, the surveys
were not conducted on a national scale in either country.
Nevertheless, core data were collected to pinpoint health
care awareness in barbershops/salons in Japan and Thai-
land. Because the study design was cross-sectional, we
were unable to determine causality. However, this study
can be a cornerstone in developing a future barbershop/
salon project in Asia. Although international compari-
sons are challenging due to the different circumstances
involved, an innovative solution can surely be found.
13
Journal of Community Health
Implications for Community Health
Regular health checks and collaborative therapy/care pro-
vided at barbershops/salons have the potential to improve
community health. However, any such project must be evi-
dence based and its effectiveness assessed. Simple proce-
dures and appropriate training are necessary for continuity.
A new system for health promotion could also be economi-
cally beneficial for barbers/stylists [10].
Conclusion
In Japan, barbers/stylists already provide health-promo-
tion-related services to customers due to the country’s
super-aging society. Health contribution awareness was
also significantly higher in Japan than in Thailand. In both
countries, some shops were willing to collaborate with
health care professionals. As collaboration between bar-
bers/hairdressers and health care professionals is possible
in Asia, further development of the barbershop/salon pro-
ject is necessary.
Acknowledgements  The authors would like to thank all the partici-
pants. This study was funded by the Toyota Foundation Research Grant
Program (D15-R-0234). The founders had no role in study design,
data collection and analysis, decision to publish, or preparation of the
manuscript.
Compliance with Ethical Standards 
Conflict of interest  The authors declare that they have no conflict of
interest.
Ethical Approval  This study was ethically approved (registration num-
ber 1635 by Akita University, registration number 307/2560 by the
Faculty of Associated Medical Sciences, Chiang Mai University, and
registration number 36/2560 by Suranaree University of Technology).
It was also registered trial at UMIN in Japan (registration number
UMIN000026106).
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