Barbershop-based blood pressure programs are put to the test

Barbershops might be a favorite gathering place in some communities, but can launching health programs there help a population lower its blood pressure?

Dr. Ronald Victor, associate director of the Cedars-Sinai Heart Institute, spent 10 months studying about 1,300 hypertensive African American men in 17 barbershops to determine the feasibility of barbershop-based health programs. We spoke last week about how his study worked - and about what he found.

What are barbershop-based health programs and how long have they been around?

To my knowledge, the first barbershop screening program was for blood pressure. It was barbershops and beauty salons in the late ‘80s to early ‘90s in Baltimore and New Orleans associated with the Association of Black Cardiologists and the International Society on Hypertension in Blacks. These were demonstration projects to see if you could screen for high blood pressure in those settings. Since then, there have been an increasing number of these barbershop screening programs, not just for blood pressure, but for prostate cancer, cholesterol and colon cancer screenings. The majority have been covered by the media, but not submitted for peer-review publication. Or if they were published in a medical journal, it was a description of the program with little or no data.

My colleagues and I started with three pilot studies in Dallas with three barbershops. We began by having medical students in the barbershops over the summer to do the blood pressure screening. At first, we didn't ask the barbers to take an active role. Then, we realized it would never be practical to hire enough medical students to do this. We really wanted this to be owned by the community. We had encouraging results from our non-randomized feasibility studies in three barbershops. We designed a formal randomized trial in 17 shops. That's the history of it.

What training did the barbers received in order to administer blood pressure checks?

For the first 10 weeks, all the barbershops - before we knew which group they'd be assigned to - had field staff there measuring blood pressure and doing interviews about blood pressure. The barbers were watching that, so they got to see what they'd be taking over later. The shops were assigned to the intervention or control group. My staff and I would meet each group of barbers when they were off. I trained them on how to measure blood pressure using electronic monitors. They would measure blood pressure on each other and on us. We trained them about verbal informed consent. We taught them about blood pressure in general and about the use of all the intervention materials. We'd work with them until we felt they knew how to work with the materials. Then, for at least the first few days or weeks, depending on the barbers, our staff would be there to coach them. We'd meet every so often to see if there were any issues. Most of the barbers, after the first day or two, felt very comfortable doing this.

What did these interactions between barber and patron look like? And did the barbers advise patrons based on their blood pressure readings?

A gentleman would sit down for his haircut and the barber would say, ‘May I offer you a free blood pressure check?' Over 80 percent of the customers said yes. For most of the men that agreed, [the barber] would put the cuff on then do the haircut. At the end of the haircut, when the customer was nice and relaxed, [the barber would] inflate the cuff and get three readings. They would write down the third reading. When that cuff gets inflated, sometimes there is a startle and the blood pressure is higher than it should be the first time. They'd write [the third reading] on an encounter form.

The encounter form would say what the limit for blood pressure should be. [The barber] would compare the reading they got and check a box depending whether the blood pressure was normal or high. If the blood pressure was normal, they would congratulate the patron and that would be it. If the blood pressure was high, they'd say, ‘We'd really like you to follow up with a doctor.' If [the patron] didn't have a regular doctor, [the barber would say] ‘Would you like us to get you one?' If the answer was yes, the barber would pick up his cell phone and call our study staff who would then talk to the patron about their insurance. If the patient didn't have health insurance and needed to go to a safety net clinic, they would schedule that appointment for them. The barbers weren't prescribing medicine or anything like that.

We gave the barbers business cards. There was a place on the business card to write down the blood pressure they recorded. The customer would take the card to their doctor, have the doctor sign it and then bring the card back with a pill bottle. The customer would get a free haircut and the barber would get a very nice tip. For most men with high blood pressure, diet and exercise are not going to be enough to get their blood pressure down. We really wanted them to go have a visit with the doctor and either start medication or get better medicine.

What were the results of your trial?

The baseline data indicated that about one-third of the hypertensive men in the barbershop already had their blood pressure treated and controlled to adequate levels. That meant that two-thirds were uncontrolled. By the end of the study, the control rates improved in both groups. There was an additional 10-percentage point increase in the comparison group that had the baseline screening and health education pamphlets. But there was almost a 20 percent improvement in the barber-based intervention groups. Blood pressure fell roughly five millimeters of mercury systolic in the comparison group and eight millimeters in the active intervention group. That doesn't sound like a lot. But if that were applied to millions of people, the number of heart attacks and strokes and heart failure and kidney failure that would be prevented would be huge.

What's next? Should this model be replicated throughout the country?

This was a proof-of-concept study. It's very exciting, but a lot more work needs to be done before it's exported around the country. The key issues are going to be sustainability and scalability. We need to find out how to make this as streamlined and as cost effective as possible. We paid the barbers financial incentives to take part in this. We paid the participants in free haircuts. We need to minimize the financial payout and find how to make this intrinsically motivating. We're piloting the next phase in Pasadena. We want to figure out what parts are really important and what parts can be let go to make it as easy as possible, so we can have a prepackaged program. If we get a refined model, then it'd be time for another randomized trial.

Image: Dr. Ronald Victor

This post was originally published on Smartplanet.com