The sample characteristics of the 76 participants are described in Table 1. The median (IQR) age of the 76 participants was 35.5 (30–45) years (Table 1). The majority of the participants were foreign-born (80.3%, n = 61). Almost one-half of the participants identified as African (47.4%, n = 36), and one-third (32.9%, n = 25) identified as Afro-Caribbean. Among the African subgroup, almost three-quarters were from Ivory Coast (47.2%, n = 17) or Mali (25.0%, n = 9). Among the Afro-Caribbean subgroup, an overwhelming majority were Jamaican (84.0%, n = 21). Educational attainment was approximately equally distributed in the sample, with 30.3% (n = 23) of the participants having a primary school education at most, 34.2% (n = 26) having a high-school degree, and 35.5% (n = 27) having a post-high-school education. While pregnant women were not actively sought out for our study, 13.2% (n = 10) of participants reported being pregnant at the time of interview or having given birth to a child within the last year. We observed that about 13.0% (n = 10) complained of stubborn acne, about 9.0% (n = 7) experienced blue-black darkening of skin, and 35.5% (n = 27) complained of stretch marks, while a small number (24.5%, n = 11) stated that they experienced other skin problems, such as skin irritation or skin that bruised when touched.
The modified MELASQOL scores ranged from a minimum of 10 to a maximum of 64. The median score was 14 (10–26). Participants with only a primary school education had the highest median score of 20 (12–30), followed by 14 (10–38) and 10 (10–22) for those who had high school and post-high-school educations, respectively. The most noteworthy responses for the MELASQOL—that bothered participants sometimes, most of the time, or all the time—were in relation to the appearance of skin color (34.3%, n = 26), frustration about skin color (26.4%, n = 20), embarrassment about skin color (24.0%, n = 18), and a restricted sense of freedom (24.0%, n = 18). Slightly under one-tenth (9.2%, n = 7) of participants also said that they had feelings of not being attractive, which bothered them all the time. Additionally, while exploring the motivations behind skin bleaching, we found that 10.5% (n = 8) of participants initiated the practice based on the recommendation of a family member or friend, which points to the fact that social networks are an important consideration.
Skin Bleaching Practice Intensity
The median age at which the participants first started bleaching their skin was 19.5 (16–25) years, yielding a median duration of skin bleaching of 13.5 (6–23) years (Table 1). About two-thirds (65.8%, n = 50) of the participants reported using only one skin bleaching product, as compared to at least two products. Nearly half (44.7%, n = 34) of the participants reported bleaching their entire body, whereas the remaining participants (55.3%, n = 42) were found to be bleaching the other parts of their body, such as their face, neck, arms, legs, etc., in different combinations. More than three-quarters (77.6%, n = 59) of the participants applied skin bleaching products to their skin on a daily basis.
Duration of skin bleaching was significantly associated with educational attainment, age, nativeness, and ethnicity (Table 2). The median (IQR) duration of skin bleaching was longest, at 24 (19–28) years, for those with a primary school education at most, compared to 10.5 (4–18) years and 8 (5–17; p < 0.001) years for those with high-school and post-high-school educations, respectively. There was a moderately positive correlation between age and duration of skin bleaching (Spearman r = 0.55; p < 0.001). The median (IQR) duration of skin bleaching was almost threefold longer for non-US-born participants, at 17 (8–24) years, than for US-born participants, at 6 (4–13; p = 0.016) years. With respect to ethnicity, the median duration of skin bleaching was longest for African participants, at 20 (9–26) years, and shortest for those in the Other group, at 6 (5–16) years. A median duration of skin bleaching of 12 (8–21) years was observed for Afro-Caribbean participants (p = 0.046). Since duration of skin bleaching was correlated with age, we conducted a post hoc assessment to determine whether the observed associations between educational attainment, nativeness, and ethnicity could be explained by differential distributions in age. Educational attainment was negatively associated with age (p = 0.02), with a median age of 42 (38–47) years among those with a primary school education, and 33.5 (28–39) years and 33 (28–44) years, respectively, for those with high-school and post-high-school educations, respectively.
Pregnancy status and ethnicity were the only risk factors associated with the number of skin bleaching products used by participants (Table 3). None of the women who were pregnant at the time of interview or who had given birth within the last year had used ≥ 2 products, compared to 39.4% (n = 26; p = 0.013) of the other women. Less than two-thirds (60.0%, n = 15) of Afro-Caribbean participants used ≥ 2 products, compared to 16.7% (n = 6) among Africans and one-third (33.3%, n = 5; p = 0.002) among the Other group.
We observed statistically significant associations between educational attainment, nativeness, and daily use of skin bleaching products (Table 4). More specifically, higher proportions of those with a primary school education (82.6%, n = 19) or a high school education (92.3%, n = 24) than those with a post-high-school education (59.3%, n = 16; p = 0.0038) used skin bleaching products daily. The proportion of foreign-born participants (85.2%, n = 52) who used skin bleaching products daily was almost twofold higher than that of US-born participants (46.7%, n = 7; p = 0.003).
Lastly, we observed a significant statistical association between nativeness and whether participants bleached their entire body (Table 5). Half of those who were foreign-born (50.8%, n = 31) reported bleaching their entire body, compared with one-fifth of US-born participants (20.0%, n = 3, p = 0.032).