SummaryTrained barbers in African-American–owned shops provide ongoing monitoring of blood pressure to African-American male patrons during each haircut, along with education and feedback designed to encourage those with elevated blood pressure to visit the doctor. Hypertensive patrons without a regular physician receive a referral to either a community physician or a local safety net clinic. Those who visit their doctor receive their next haircut free of charge, while barbers receive incentives for recording blood pressure, assisting with referrals for those without a regular doctor, and getting patrons to visit the physician for treatment. The program significantly improved treatment rates and blood pressure control in hypertensive patrons.Strong: The evidence consists primarily of a cluster randomized trial comparing blood pressure control rates in 9 participating barber shops (with an average of 77 hypertensive patrons per shop) with a group of 8 similar barber shops (with 75 patrons per shop) offering only educational pamphlets about hypertension; results from two smaller, nonrandomized feasibility studies are also included.
Developing OrganizationsCedars-Sinai Heart Institute
Two nonrandomized studies tested the feasibility of the program between 2002 and 2005. A cluster randomized trial of the program ran from March 2006 to December 2008.
Patient PopulationThe program serves African-American men with hypertension. During the cluster randomized trial, the vast majority of participants had some form of health insurance, and they often had other risk factors, including family history of hypertension (83.3 percent), smoking (22.1 percent), diabetes (19.2 percent), high body mass index (mean of 31.4), high cholesterol (44.2 percent), and prior stroke, heart attack, or heart failure (13 percent).8Race and Ethnicity > Black or African American; Gender > Male; Vulnerable Populations > Racial minorities
Problem AddressedMany African-American men have uncontrolled high blood pressure, which can lead to premature disability and death. These men often do not go to a physician for routine monitoring, creating the need for new venues, such as barber shops, for effectively monitoring blood pressure and encouraging individuals to get their condition treated.
- Many with uncontrolled hypertension, leading to premature disability and death: Nearly 40 percent of African-American adult men in the United States (roughly 4.4 million individuals) have hypertension, 70 percent of whom do not have the condition under control.1 Uncontrolled hypertension represents one of the leading causes of premature disability and death in this population, with African-American men suffering a higher death rate from hypertension than any other racial, ethnic, or gender group.2,3
- Failure to seek preventive care: African-American men have less frequent contact with physicians related to preventive care than do many other racial and ethnic groups, including African-American women.1,4
- Unfilled need for new, trusted venues: The Centers for Disease Control and Prevention (CDC) has called for the development of community-based outreach programs targeting hypertensive African-American men, with the goal of delivering messages that resonate.2 African-American–owned barber shops often draw large, loyal followings and serve as a trusted venue for open discussions with influential peers on numerous topics, including health. Barber shops and hair salons have periodically served as a venue for screening programs since the 1980s, without any systematic evaluation of these efforts.5,6 Recently, promising results been reported in nonrandomized feasibility studies, and hence barber shops represent a significant, untapped opportunity to promote hypertension control in African-American men.7
Description of the Innovative ActivityTrained barbers provide ongoing monitoring of blood pressure to African-American adult male patrons at each haircut, along with education and feedback designed to encourage those with elevated blood pressure to visit the doctor. Hypertensive patrons without a regular physician receive a referral to either a community physician or a local safety net clinic. Those who then visit their doctor receive their next haircut free of charge, while barbers receive financial incentives for recording blood pressure, requesting referrals to a physician, and successfully connecting patrons to physicians. Key program elements are described below:
- Screening at every haircut: Whenever an adult African-American patron comes in for a haircut, trained barbers ask if they would be interested in participating in the program. Interested patrons give their consent and then have their blood pressured measured. The barber typically conducts the measurement three times toward the end of the appointment (when the patron tends to be relaxed, thus allowing for a more accurate reading).
- Recording reading on card: The barber records the final reading on a card given to the patron. The card includes a place to designate if the patron has diabetes, along with thresholds to determine if the patron has high blood pressure (135/85 mm Hg or above for nondiabetics and 130/80 mm Hg or above for those with diabetes). During a cluster randomized trial of the program in 8 Dallas-area barber shops, 77 percent of hypertensive patients had their blood pressure checked on a regular basis, with the average patron having 8 completed readings over a 10-month period.8
- As-appropriate feedback, education, and referrals: Based on the results from the blood pressure check, barbers provide feedback, education, and physician referrals, as outlined below:
- Positive reinforcement for in-control readings: Barbers provide positive feedback to those who have normal blood pressure. They praise the patron and note that they would like to continue monitoring their blood pressure at future appointments to make sure no problems develop. If subsequent readings remain normal, the monitoring may cease after several checks.
- Education focused on need to see physician for out-of-control readings: For those with high blood pressure, the barber provides male-oriented educational messages about the importance of seeing a physician to manage the condition, often engaging other male patrons to create a group discussion.
- Eliciting and responding to patron perspective: During these conversations, the barber attempts to elicit the patron's perspective on the high reading and engage him accordingly. For example:
- Some patrons may already be thinking about seeing a doctor, in which case the barber attempts to provide the "nudge" they need.
- Some patrons may deny the problem (e.g., blaming the reading on a "one-time" issue such as having just consumed a high-sodium meal), in which case the barber suggests continued monitoring at the next appointment. Over time, readings often establish a pattern of high blood pressure that the patron can no longer dismiss.
- Some patrons may already be on blood pressure medication, in which case the barber focuses on the need to inform the doctor of the high reading and consider a change in the drug and/or dosage.
- Sharing stories of other patrons: As appropriate, the barber tells the stories of other patrons of the same shop who have accessed treatment and seen improved results because of this program. Large posters on the shop's walls tell these real-world stories, thus helping to make the story come alive to patrons. During the aforementioned randomized cluster trial, 51 percent of patrons heard a model story at every haircut and another 32 percent heard the stories at half of their haircuts.8
- Referrals for those without a doctor: For anyone with elevated blood pressure who does not have a regular physician, the barber calls a medical assistant affiliated with the program while the patron is still in the shop. If possible, this individual speaks directly with the patron, inquiring about his insurance status and then setting up an appointment with a local community physician (for insured patrons) or safety net clinic (for those without insurance). Ideally, the patron leaves the barber shop with an appointment in hand, in some cases for the same day.
- Blood pressure card: Patrons with out-of-normal-range readings receive a folded, four-sided referral card. Half of the card is for the physician to review, with one side having the patron's name and the other containing the most recent blood pressure reading with the date and barber's initials. The other half includes a place for the doctor to sign verifying that the patron has sought treatment, along with a "coupon" for a free haircut (see below for more details). The patron takes this half of the card with him after the doctor visit.
- Financial incentives for barbers and patrons: The program includes incentives for both the patrons and the barber; the type and size of these incentives can vary. During the cluster randomized trial, patrons with elevated blood pressure who saw a physician (as verified on the aforementioned card) qualified for a free haircut at their next appointment. Barbers received $3 for each blood pressure reading recorded, $10 for every phone call made to the nurse requesting referral assistance, and $50 for every blood pressure card returned with a physician's signature, thus verifying that a physician–patient interaction had taken place.
References/Related ArticlesVictor RG, Ravenell JE, Freeman A, et al. Effectiveness of a barber-based intervention for improving hypertension Control in black men. The BARBER-1 study: a cluster randomized trial. Arch Intern Med. 2010 Oct 25 [Epub ahead of print] [PubMed]
Hess PL, Reingold JS, Jones J, et al. Barbershops as hypertension detection, referral, and follow-up centers for black men. Hypertension. 2007;49(5):1040-6. Epub 2007 Apr 2. [PubMed]
Victor RG, Ravenell JE, Freeman A, et al. A barber-based intervention for hypertension in African American men: design of a group randomized trial. Am Heart J. 2009;157(1):30-6. [PubMed]
Khanna RR, Victor RG, Bibbins-Domingo K, Shapiro MF, Pletcher MJ. Missed opportunities for treatment of uncontrolled hypertension at physician office visits in the United States, 2005 through 2009. Arch Intern Med. 2012 Sep 24;172(17):1344-5. [PubMed]
Contact the InnovatorRonald G. Victor, MD
Associate Director, Clinical Research
Director, Hypertension Center
Cedars-Sinai Heart Institute
8700 Beverly Blvd., 141 RBT, Suite 210
Los Angeles, CA 90048
Julie Groth, MPH
Administrative Services Associate, Hypertension Center
Cedars-Sinai Heart Institute
8700 Beverly Blvd., 141 RBT, Suite 210
Los Angeles, CA 90048
Innovator DisclosuresDr. Victor and Ms. Groth have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
ResultsMultiple studies show that the program has increased treatment rates and improved blood pressure control in hypertensive African-American males.
Strong: The evidence consists primarily of a cluster randomized trial comparing blood pressure control rates in 9 participating barber shops (with an average of 77 hypertensive patrons per shop) with a group of 8 similar barber shops (with 75 patrons per shop) offering only educational pamphlets about hypertension; results from two smaller, nonrandomized feasibility studies are also included.
- Increased treatment rates: Both randomized and nonrandomized studies show that the program increased treatment rates, as outlined below:
- Cluster randomized trial: In a study comparing patrons of 8 participating Dallas-area barber shops with similar patrons of other barber shops offering only educational pamphlets tailored to African-American males, the proportion of hypertensive patrons in participating shops who received treatment increased by 11.2 percentage points, from 67.9 percent at baseline to 79 percent after 10 months in the program. By contrast, treatment rates among patrons of shops offering educational pamphlets increased by only 6.2 percentage points, from 69.9 to 76.1 percent.8 Overall, 51 percent of 350 participating patrons with elevated blood pressure readings had documented visits to their physicians, including roughly 10 percent (36 patrons) who received nurse assistance in securing an appointment.8 Presumably, the program's impact would be even greater if it had been compared to a "usual care" group of patrons receiving no education about hypertension.
- Nonrandomized feasibility studies: Two earlier studies found that an 8- and 14-month version of the program improved treatment rates; one study compared rates in participants with a nonrandomized comparison group of patrons in the same barber shops who did not participate, while the second study tracked treatment rates over time as patrons had more exposure to the program.9
- Better blood pressure control: In the cluster randomized trial described above, average systolic blood pressure among participants fell by 7.8 points (from 137.6 to 129.8 mm Hg) during the 10-month program, compared with a 5.3-point decline among patrons of barber shops offering educational pamphlets. Diastolic blood pressure fell by 2.8 points among participants (from 81.5 to 78.7 mm Hg), compared with 1.9 points among patrons of the other shops. Overall, the percentage of hypertensive participants with their blood pressure under control increased by roughly 20 percentage points (from 33.8 percent at baseline to 53.7 percent), nearly double the 11.1 percentage-point increase (from 40 to 51 percent) among patrons of shops offering educational pamphlets.8 The earlier feasibility studies also found that participants exhibited improved blood pressure control as a result of the program.9
- Potential to save lives without increasing costs: A very conservative simulated analysis suggests that the program, if adopted broadly, could save lives without significantly increasing costs (and potentially even reducing them):
- Saving lives: Assuming the program produced a 2.5-point decline in systolic blood pressure (as it did in the cluster randomized trial as compared with those exposed to educational pamphlets), adoption by all 18,000 black-owned barber shops in the United States would prevent an estimated 800 heart attacks, 550 strokes, and 900 deaths in the first year. (These shops collectively serve approximately half of African-American men with high blood pressure.) This conservative analysis very likely understates the true life-saving potential of the program because lower blood pressure will continue to yield health benefits beyond the first year of the program for some participants, and the 2.5-point decline likely underestimates the true impact the program would have versus a usual-care group receiving no education. The 7.8-point decline experienced by participants during the course of the 10-month program may be a more accurate indicator of the program's potential, and using this figure in the analysis would lead to a higher estimate of saved lives.
- Potentially reducing costs: Excluding program costs, the 2.5-point decline highlighted above would translate into more than $100 million in savings due to lower health care expenditures, or roughly $50 per patron. Incentive costs averaged $133 per patron during the trial,8 which means that, conservatively speaking, these savings represent nearly 40 percent of the incentives and hence lower the "net" cost of the program substantially. However, potential cost savings would be much higher if less conservative estimates were used for the blood pressure–lowering potential of the program (as discussed earlier). In addition, program leaders hope to reduce incentive and other program-related costs going forward without negatively affecting results. Consequently, they believe the program has the potential to save money as well as lives. (See the Resources Used and Skills Needed section for more information on program costs.)
Context of the InnovationPart of the Cedars-Sinai Medical Center, the Cedars-Sinai Heart Institute focuses on prevention, diagnosis, treatment, management, and research related to diseases, conditions, and disorders of the heart and vascular system. The institute offers a full range of noninvasive and invasive procedures and services. The impetus for this program came from Dr. Victor (a cardiologist and hypertension specialist) and his research team, who became concerned about the large gap in hypertension control between African-American men and women. In response to the CDC recommendations noted earlier, they began looking for potential ways to get effective messages to African-American adult males. After researching the issue, the group decided that African-American–owned barber shops could be an effective venue for education because they cater to large numbers of men who do not engage in the health care system and serve as a comfortable gathering place in which men socialize on a regular basis. In addition, barber shops and hair salons had served as venues for similar types of interventions in the past.
Planning and Development ProcessKey steps included the following:
- Designing program based on acquired immunodeficiency syndrome (AIDS) projects: Researchers adapted the program from the CDC's successful AIDS Community Demonstration Projects, which equipped community peers to deliver actionable messages using role models.10 The AIDS program promoted specific actions for target audiences to take (i.e., cleaning needles before injecting drugs and using protection during sex). To that end, the program equipped peers with bleach kits and condoms to be distributed. Similarly, the hypertension program equipped barbers with the tools they needed to convince hypertensive men to seek treatment.
- Conducting feasibility studies and creating posters: The program was tested in several feasibility studies conducted in a small number of shops. During these studies, researchers collected stories of individual patrons who had benefited from the program, and then produced posters highlighting the story for placement within the barber shop they frequented. Poster development continued during the larger randomized trial so that more participating shops could make use of real-world stories from that shop.
- Equipping and training barbers: During the randomized trial, each barber received training on how to use a state-of-the-art, research-grade blood pressure machine, along with education on how to interpret results and engage effectively in a dialogue about hypertension with patrons. Training occurred over a period of several hours when the shop was closed (typically on Monday mornings). During the session, barbers viewed a demonstration and then practiced taking blood pressure and interpreting results with research staff and other barbers. They also engaged in role-play exercises to learn how to encourage hypertensive patrons to seek physician care, including how to incorporate the role-model stories (and accompanying posters) into the conversation, communicate with the nursing assistant handling referrals, and fill out the requisite paperwork. Training emphasized the need to encourage patrons without coming across as being coercive. (Some of the training also related to how to obtain informed consent for participation in a research study, which would not be necessary in the absence of such a trial.)
- Monitoring during first few days of operation: During the randomized trial, the program typically commenced on the day after the training session (usually a Tuesday, which tends to be fairly slow for many shops). To ensure barber comfort with the program, researchers came to the shop for the first day or two to assist barbers facing any difficulties. After a few days with this additional support, most barbers felt quite comfortable with the program.
- Ongoing testing and refinement: Since the conclusion of the cluster randomized trial conducted in Dallas, TX, program leaders continue to test and refine the program. For example, the same basic approach is currently being tested in a limited geographical area in Los Angeles. As noted, program leaders are also exploring options for reducing the costs of the financial incentives without undermining program effectiveness.
Resources Used and Skills Needed
- Staffing: The program requires several dedicated staff, as outlined below:
- Referral coordinator: The program requires someone to make referrals for patrons without a regular doctor. This person need not have medical training but must have good people and organizational skills. During the various trials completed to date, a licensed vocational nurse, medical student, and research coordinator have served in this capacity. Assuming this individual has no study-related duties, one full-time equivalent could likely handle 12 to 24 barber shops, although this figure will vary based on the size of the shops.
- Incentives coordinator: Depending on the complexity of the incentives offered, the program likely requires one full-time administrative person to monitor and oversee payment of the various incentives.
- Physician oversight: A physician should likely be designated to oversee the program in case issues arise with individual patrons, although this role would likely not take up a meaningful amount of time. This individual may also play a role in conducting the initial training of the barbers.
- Costs: Data on total program costs are unavailable. The bulk of such costs consist of the incentives, which averaged $133 per hypertensive patron during the cluster randomized trial ($112 for the barber incentives and $21 for the free hair cuts).8 As noted, however, would-be adopters may not need such generous incentives, particularly for the barbers. These figures exclude the upfront cost of the blood pressure machines and the ongoing costs of salary and benefits for the dedicated program staff outlined above.
Funding SourcesNational Heart, Lung, and Blood Institute (U.S.)
In addition to the National Heart, Lung, and Blood Institute (through grant RO-1 HL080582), other program funders include the Donald W. Reynolds Foundation, the Aetna Foundation Regional Healthy Disparity Program, Pfizer, Biovail, the Lincy Foundation, the Robert Wood Johnson Foundation (through a Harold Amos Award), the Norman and Audrey Kaplan Chair in Hypertension at the University of Texas Southwestern Medical School, and the Burns and Allen Chair in Cardiology Research at the Cedars-Sinai Heart Institute.
Tools and Other ResourcesWould-be adopters can contact the program developers to learn more about program-related materials; some of these materials have been published in online supplements to the articles listed in the References/Related Articles section.
Getting Started with This Innovation
- Conduct needs assessment: Not all communities have a need for a program focused on hypertension control; for example, those barber shops catering to a young clientele may not have many hypertensive patrons. Consequently, evaluate the major health problems within the community before determining if a program focused on African-American males and hypertension makes sense. The program could potentially be refined to target other populations and/or unmet health needs, such as encouraging patrons to receive cancer, diabetes, or cholesterol screenings (although performing such screening in the barber shop may not be feasible).
- Start small and expand over time: Implementing this program in 20 barber shops simultaneously could prove quite challenging, given the need to equip and train the barbers. A more realistic approach is to begin with one or a few shops and then expand over time at a pace dictated by available resources. During the cluster randomized trial, program developers typically enrolled 2 to 4 shops at a time.
- Include patron incentives: Although the size and type of incentives offered need not mirror those used in the randomized trial, the free or discounted haircut for patrons who see a physician should likely be a part of any program. This incentive proved to be highly popular with both patrons and barbers.
- Build relations with shop owner or manager: Implementation proceeds smoothly when the shop manager or owner understands and feels like a partner in the program. To that end, have members of the medical community meet with these individuals (and potentially patrons as well) in the barber shops to explain the program, including what specifically the barber is being asked to do and how the barber and patron incentives work. As entrepreneurs, shop owners and managers will likely respond positively once they understand how the program can benefit their patrons' health and increase customer loyalty and revenues.
- Consider avoiding use of external community advisory board: Shop owners and managers may not appreciate having someone oversee them or dealing with unnecessary bureaucracy. Rather, they expect to "call the shots" and any barber-based program must be respectful of that view. As a result, program developers should carefully consider the merits of creating a community-based advisory board outside the barbering community to oversee the program.
- Invest in training: Barbers need adequate training, including an initial session when the shop is closed followed by one-on-one support during the first few days after the program begins. Program leaders found this additional support to be critical in helping barbers accurately interpret results. To further assist with results interpretation, be sure to include the various cutoff points designating hypertension in large print on the referral card.
Sustaining This Innovation
- Give barbers freedom to make changes: Barbers likely know how to make the program work effectively with their patrons. Consequently, elicit their opinions and give them the freedom to make minor modifications as they see fit. For example, some customers come in for a haircut every other week. Because biweekly blood pressure checks are not necessary, let the barbers decide how to handle ongoing monitoring in these patrons.
- Elicit and respond to barber feedback: Regularly ask barbers how the program is working and help them resolve problems as they arise.
- Seek media attention for participating shops: Patrons receiving blood pressure screening in a barber shop make for a great media story. In particular, visual images of patrons will have broad appeal to audiences. Barbers will value any publicity and new customers that come from such coverage.
- Make ongoing participation easy: Barbers will not stick with the program if doing so takes substantial time away from their customers. Consequently, never make the barbers travel offsite for any aspect of the program, including initial training and ongoing interactions.
- Do not bring barbers from different shops together: Barbers in different shops may view each other as competitors and/or may not have good chemistry. Consequently, all training and subsequent interactions should be done one barber shop at a time.
- Monitor program effectiveness and refine as necessary: To the extent possible, monitor the program's impact on treatment rates and blood pressure control. If results do not match expectations, discuss problems with participating barbers and refine program elements accordingly. The size and structure of incentives will likely prove critical to program effectiveness and may need to be tweaked over time.
Additional Considerations and Lessons
- Consider use with other populations and conditions: As noted earlier, a similar type of program could potentially target other populations, including women (in hair salons) and other racial or ethnic groups. This type of program could also promote other health-related behaviors, such as being screened for certain types of cancer or receiving appropriate care for the prevention and/or management of chronic disease (e.g., diabetes, asthma, cardiovascular disease, stroke).
Use By Other Organizations
- As noted, a similar program is currently being tested with African-American–owned barber shops in parts of Los Angeles. As a slight variation on this program, an ongoing Chicago-based initiative brings a barber into a safety-net clinic to focus on hypertension in men. Other barber- and salon-based programs exist in many major cities, although most use lay health coordinators or medical volunteers rather than the barber or stylist to work with patrons. Often these programs operate on a sporadic basis (e.g., screening days held once or twice a month) rather than being a part of everyday operations. Examples of this approach include programs offering breast cancer screening and stroke prevention education for women and prostate cancer screening in men.
Cutler JA, Sorlie PD, Wolz M, et al. Trends in hypertension prevalence, awareness, treatment, and control rates in United States adults between 1988-1994 and 1999-2004. Hypertension. 2008;52(5):818-27. [PubMed]
2 Centers for Disease Control and Prevention. A Closer Look at African American Men and High Blood Pressure Control: A Review of Psychosocial Factors and Systems-Level Interventions. Atlanta, GA: US Dept. of Health and Human Services; 2010.
Lloyd-Jones D, Adams R, Carnethon M, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2009;119 (3):480-6. [PubMed]
Victor RG, Leonard D, Hess P, et al. Factors associated with hypertension awareness, treatment, and control in Dallas County, Texas. Arch Intern Med. 2008;168(12):1285-93. [PubMed]
5 Harris-Lacewell MV. Barbershops, Bibles, and BET; African Americans; Politics; Government. Woodstock, England: Princeton University Press; 2006.
Hess PL, Reingold JS, Jones J, et al. Barbershops as hypertension detection, referral, and follow-up centers for black men. Hypertension. 2007;49(5):1040-6. [PubMed]
7 Murphy M, Hansgen HC. Barbershop Talk: The Other Side of Black Men. Merrifield, VA: Melvin Murphy; 1998.
Victor RG, Ravenell JE, Freeman A, et al. Effectiveness of a Barber-based intervention for improving hypertension control in black men. The BARBER-1 study: a cluster randomized trial. Arch Intern Med. 2010 Oct 25. [Epub ahead of print] [PubMed]
Hess PL, Reingold JS, Jones J, et al. Barbershops as hypertension detection, referral, and follow-up centers for black men. Hypertension. 2007 May;49(5):1040-6. Epub 2007 Apr 2. [PubMed]
CDC AIDS Community Demonstration Projects Research Group. Community level HIV intervention in 5 cities: final outcome data from the CDC AIDS Community Demonstration Projects. Am J Public Health. 1999;89(3):336-345. [PubMed]
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Service Delivery Innovation Profile
Original publication: March 30, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: March 27, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: March 13, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.