Black-owned barbershops are rapidly gaining traction as potential community partners for health promotion programs targeting HTN as well as diabetes, prostate cancer, and other diseases that disproportionately affect black men.1;11;13-17;29
Yet the effectiveness of barbershop-based HTN screening and referral programs on BP control previously has not been evaluated by a randomized trial. In this cluster-randomized controlled trial, we found that an enhanced intervention program—in which barbers continuously monitored BP and actively promoted physician-follow-up with personalized gender-specific messages—resulted in improved BP control among black male barbershop patrons with HTN. Although BP control also improved in a comparison group, which received standard written information about high BP, the improvement was greater with the enhanced intervention. A statistically borderline intervention effect was seen for medication treatment rates, BP levels, and other secondary outcomes. Thus, the results of this study provide the first evidence for the effectiveness of a barber-based intervention for controlling HTN in black men and indicate that more research is needed to develop a highly effective and sustainable intervention model prior to large-scale program implementation.
We detected a positive intervention effect despite an unexpectedly large improvement in BP control in the comparison group, which was not an inactive comparator. In collecting thorough baseline BP data, we unavoidably intervened in both groups: patrons with HTN in all participating barbershops were repeatedly exposed to research staff measuring their BP at two baseline haircut visits, and due to ethical reasoning, gave those with elevated BP readings detailed written recommendations for physician follow-up. In addition to this Hawthorne effect, educational pamphlets written for black individuals were distributed only to comparison shops.
The larger improvement in HTN control seen in the intervention group is not explained by baseline values, which were taken into account by the mixed-effects model. Moreover, within either group, shops with lower baseline values did not show larger increments in HTN control and there was no ceiling effect.
The new data confirm and extend our earlier pilot data11
by indicating that the characteristic long-term patronage in black-owned barbershops (almost a decade) and frequent haircut visits (1 every 3-to-4 weeks) provided much opportunity for barbers to repeatedly monitor BP and deliver intervention messages. The process data indicate that, in general, the intervention was implemented as intended. That barbers measured BP on 3 of every 4 patrons with HTN and that each of the participating patrons averaged 8 barber BP checks in 10 months shows reasonably high levels of intervention implementation and penetration. That the barbers motivated 50% of their patrons with elevated BP readings to visit a physician supports the theoretical underpinning of the behavior theory-based intervention, namely, that barbers, as influential peers, can increase HTN treatment-seeking behavior. The intervention effect on primary and secondary BP outcomes may have been larger than observed if barbers had motivated the other 50% of high BP patrons to see a physician.
A salient finding is the middle-income status of the barbershop clientele. Although most participating barbershops were in low-income areas, patrons need financial resources to afford frequent haircuts. Because socioeconomic status and affordability of health insurance are major determinants of HTN control,1
the low baseline HTN control rates among the barbershop patrons may seem disproportionate to income level and healthcare access. However, for reasons that require more study, middle-income status alone does not protect black men from many poor health indicators, including under-utilization of available medical services to control HTN and prevent its complications.30
For example, socio-cultural factors related to masculinity (such as a desire to avoid showing vulnerability) also can deter men from fully utilizing available preventive medical services.4;30
Our data suggest that barbers can deliver health messages which resonate with men and, more broadly that the barbershop constitutes a unique opportunity for further research on improving the health status of this particularly vulnerable and under-studied group of men—middle-income black men.1;30
Our study has several important limitations. The impact of the barber-based intervention was less than optimal because not all barbers participated fully and not all patrons agreed to have their BP monitored and be referred for physician follow-up. Because study sites were confined to one county, the results cannot be generalized to other geographic areas without further study. Because the barbershops' clientele were predominately middle-income, the intervention had limited ability to reach very low-income individuals who will require other types of intervention. The evaluation strategy provided a snapshot of BP improvement at one point in time and does not demonstrate whether the outcomes are sustainable, particularly because financial incentives were paid to barbers for conducting the intervention and to patrons for following their advice in seeking medical attention. However, the $112 incentive paid per barber per hypertensive patron and the $21 paid per patron in free haircuts for HTN-related physician visits is far less than the $750 cash incentive per patient used in a recent smoking-cessation study.31
Because hypertensive patrons choose their individual physicians, we could not collect actual data on increased antihypertensive treatment costs associated with the intervention. Our CHD Policy Model simulation indicates that the projected cost savings from reduced HTN-related cardiovascular disease (CVD) events in the first year alone would substantially offset intervention costs. More extensive simulations are needed to project the cost savings and quality adjusted life-years from reduced CVD that would accumulate beyond the first year (including long-term care savings from prevented strokes, etc), particularly if the modest reductions in systolic BP observed in BARBER-1 could be sustained or augmented in this high-risk black male population.28;32;33
Despite these limitations, the study establishes an important precedent for future quantitative evaluation research on this and other health promotion programs in barbershops. The results provide proof-of-concept for one effective barber-based intervention, which lowered systolic BP by ~8 mmHg from baseline—2.5 mmHg more than in the comparison group. Based on the observed intervention effect of an 8.8% greater improvement in HTN control rate, we estimate that 12 hypertensive black male patrons would need to be exposed to this intervention to achieve BP control in one more patron.
The study addresses the newly recommended policy shift from traditional case-management to develop novel population-based systems and community-based support for persons with HTN.34
The data add to an emerging literature on the effectiveness of community health workers in the care of people with HTN,35
as contemporary barbers constitute a unique workforce of community health workers whose historical predecessors were barber-surgeons.36
Future studies should evaluate the potential effectiveness of the intervention in other urban centers, alternative incentive structures, comparative effectiveness of the intervention with and without certain components (e.g., model stories), and project long-term cost-effectiveness of alternative strategies (e.g., targeting barbershops with a mainly older clientele to enhance screening efficiency and prevent more HTN-related events). The public health potential is intriguing.