Barbershops a Cut Above for BP Checks in African American Men

October 29, 2010

October 29, 2010 (Chicago, Illinois) — In the Texas of 150 years ago, the town barber was probably also the guy who pulled an aching tooth. A cadre of barbers in today's Texas were true to their healthcare-provider heritage by participating in a hypertension-screening outreach experiment that helped many of their customers with hypertension to get their blood pressures under control.

In a unique randomized trial [1], African American men who were patrons of black-owned barbershops in Dallas County, where they had their BP regularly measured and were encouraged to contact a physician when it was elevated, showed a mean 7.8-mm-Hg drop in systolic pressure over 10 months.

That was only 2.5-mm-Hg more of a drop (p=0.08) than seen in a comparator group of men who had received standard educational pamphlets on high BP in African Americans, but no BP checks or other encouragement to assess blood pressure, at the barbershops.

"That doesn't sound like much of a blood-pressure fall for any one person, but at the population level it's a very large effect," lead author Dr Ronald G Victor (Cedars-Sinai Heart Institute, Los Angeles, CA) observed for heartwire .

A barber chair is a great setting for measuring blood pressure--much better than, say, a table in a cold examination room, where the patients are holding on with tight knuckles, legs and arms dangling.

Moreover, it wasn't the study's primary outcome. The primary outcome was change in rate of BP control among hypertensives, with BP control defined conventionally as achievement of <135/85 mm Hg for nondiabetics and <130/80 for diabetics.

By that measure, men in the intervention group did significantly better, with a BP-control rate that was 8.8 absolute percentage points higher than achieved in the comparator group (p<0.04).

The findings show that the barbershop is an effective venue for delivering health messages to a population, African American men, that is at especially high risk for hypertension and its complications, Victor and his colleagues observe in their report published online October 25, 2010 in the Archives of Internal Medicine.

The Setting as the Opportunity

"Black-owned barbershops hold special appeal for community-based intervention trials," they write, "because they are a cultural institution that draws a large and loyal male clientele and provides an open forum for discussion of numerous topics, including health, with influential peers."

And, Victor noted when interviewed, "a barber chair is a great setting for measuring blood pressure. It’s a comfortable straight-backed chair with foot rests and arm rests at heart level. It's much better than, say, a table in a cold examination room, where the patients are holding on with tight knuckles, legs and arms dangling."

Part of what made the intervention strategy work, he said, was the amount of responsibility given to the barbers themselves, who took their customers' blood pressures and encouraged them to see a doctor when appropriate.

My blood pressure was up, and the barber I was training said, listen, if you're going to talk the talk, you'd better walk the walk.

"The barbers can be looked at as sort of an indigenous work force of community health workers," Victor said. Their established relationship with the customer was central to the study's design. "Having them be the centerpiece and own the intervention--I think that was the unique aspect of the trial."

In his editorial accompanying the report [2], Dr Clyde W Yancy (Baylor University Medical Center, Dallas, TX) agrees that the barber-patron relationship was key.

"In the current study," he writes, "African American men frequenting community barbershops were exposed to health messaging and specifically hypertension screening by a trusted partner. This issue cannot be overemphasized, because the barrier of cultural competency that permeates the traditional healthcare-provider–patient interface in at-risk communities is a nonissue when a community partner assumes the task of elevating awareness, screening for risk factors, and becoming a change agent."

The idea was to have messages that really resonate with men.

Yancy further notes that while the intervention group's BP-control rate improved significantly more, the comparator group's rate also improved substantially.

"The present study therefore outlines two potentially effective community-based strategies to improve hypertension detection and control: providing culturally sensitive health-education materials . . . in a trusted venue (barbershops); and incorporating community partners (barbers) in the care of those with known risk factors for heart disease."

Victor et al, Yancy continues, "have proposed a truly novel idea and, moreover, have provided an evidence base to suggest efficacy. This model merits further development. But we must remain cautious and strictly evidence based; before we invest significant resources, more research is needed, especially to generate outcomes and cost-effectiveness data."

Victor said the trial was designed to be transferable to clinical practice even if some issues went unanswered. "We couldn't answer all our questions in one study, but we wanted to make it something close to exportable even if it required fine-tuning. The idea was to make it something that could be owned by the community and sustainable," he said. "It's our first best shot based on 10 years of pilot studies."

The Barber as Health Professional

In the trial, called Barber-Assisted Reduction in Blood Pressure in Ethnic Residents (BARBER-1), 17 black-owned barbershops with clienteles consisting almost entirely of African American men were randomized to be intervention shops (n=9, mean 75 hypertensive patrons per shop) or comparator shops (n=8, mean 77 hypertensive patrons per shop).

At intervention shops, patrons were consistently offered BP checks with their haircuts. Those with elevated pressures were encouraged to see their physicians; those without physicians were referred to the nursing staff, who helped with referrals to community physicians or hypertension clinics.

"The barbers also gave the patrons with elevated BP readings wallet-sized referral cards to give their physicians ongoing feedback--accurate out-of-office BP readings--about the need to start or intensify BP medicine regimens," Victor et al write.

Barbers were given cash incentives to perform the intervention--for example, $3 per BP assessment, $10 per nurse-referral request, and $50 per referral card signed by a physician. The patrons received a free haircut for each signed referral card.

The intervention also used a less direct form of encouragement, "peer-based health messaging," to help overcome any resistance the patrons may have had toward BP checks and, if called for, seeing a doctor.

Peers as Role Models

"Early adopters of the program became role models later on for the rest of the patrons," Victor said. They were interviewed about their motivations in participating and positive experiences in following up with their physicians. Their pictures and key quotes from the interview were displayed on posters that were hung in the shops for all patrons to see.

"The idea was to have messages that really resonate with men," Victor said. "I think men are, in general, a bit of a harder sell about being proactive about health than are women."

To make his point, Victor presented himself as just such a man who seemed to need extra prodding before confronting his high blood pressure.

The barbers can be looked at as sort of an indigenous work force of community health workers.

He played the role of customer during the training process all the barbers went through, he said, and had his BP measured repeatedly. "I was the guinea pig. My blood pressure was up, and the barber I was training said, listen, if you're going to talk the talk, you'd better walk the walk. So I went to see my internist and got started on medication. I felt like a real idiot for not doing it before that."

Victor was almost gleeful about the irony, pointing out that he was the division chief for hypertension at the University of Texas Southwestern (Dallas), currently directs the hypertension center at Cedars Sinai Heart Institute, "and am coauthor on Kaplan's Clinical Hypertension, 10th ed. So I'm guilty as charged."

Victor discloses serving on the speaker's bureau for and receiving an investigator-initiated research grant from Pfizer and receiving an unrestricted educational grant from Biovail; he also received grant support for BARBER-1 from the National Institutes of Health, the Donald W Reynolds Foundation, the Aetna Foundation Regional Healthy Disparity Program, the Lincy Foundation, University of Texas Southwestern, the Cedars-Sinai Heart Institute, Pfizer, and Biovail. Coauthor Dr Joseph E Ravenell (New York University, NY) discloses receiving support for the trial from the Robert Wood Johnson Foundation. Yancy had no disclosures.