A Shave, a Haircut, and a Blood-Pressure Test

An experimental program is using "barbershop intervention" to bring health education to African American men.

The barbershop has always been more than a place to get a trim and a shave for African American men. It’s a place to talk sports, debate politics, and swap stories. Now it may also be a site for early medical intervention for high blood pressure.

Dr. Ronald Victor, the director of Cedars-Sinai Center for Hypertension in Los Angeles, recently received an $8.5 million grant from the National Institutes of Health to test if early barbershop intervention can produce significantly better blood pressure control in African American men.

High blood pressure disproportionately affects African Americans, who develop it at younger ages than other groups in the U.S. and are more likely to develop related complications such as stroke and heart disease. African American men, in particular, suffer from a low rate of preventative care, and have a death rate from hypertension more than two times higher than that of their white counterparts.

The program will train barbers in traditionally African American communities to take their customers’ blood pressure and refer customers with elevated readings to doctors. “We have to leave the hallowed halls of medicine,” Victor explains. “Barbershops are the hub of a community.”

Victor is partnering with Dr. Anthony Reid, a cardiologist based in Inglewood, California, on the project. The study builds on an earlier one conducted in Dallas between 2006 and 2008 and published in the Archives of Internal Medicine in 2011.

The research looked at the effects of blood-pressure checks and health education promoted by barbers for 10 months in 17 barbershops on about 1,300 male patrons. In nine of the shops, barbers continually took blood-pressure checks of their patrons and referred them to physicians. In the other eight shops, patrons were given just the heart-health information, a standard pamphlet on blood pressure, without the barber-administered blood-pressure checks. The study found that while blood-pressure levels fell in both groups, the barber-assisted group showed greater improvement.

The new round of funding will allow for a larger study in Los Angeles, which is currently in the planning stages and scheduled to launch in the beginning of 2015. Victor and Reid plan to work with two dozen barbershops in LA, tracking patients for at least 18 months.

The study is partnered with healthcare providers like Kaiser Permanente and low-cost health clinics, which, along with Dr. Reid, will treat patients without insurance. According to Victor, one of the larger challenges in the Dallas study was coordinating patient care with the healthcare system. “If we had 100 regular customers with high blood pressure, they would have 99 different doctors,” he says.

The concept of the barbershop as a site for medical outreach isn’t entirely new. In the Middle Ages, barbers, rather than physicians, were expected to perform minor surgeries such as bloodletting, teeth extractions, and even give enemas. More recently, the barbershop has taken on special significance in the African American community. Prior to the pre-civil rights era, it was one of the few professions open to black men—a path to entrepreneurship and self-employment. The barbershop itself became a de facto men’s club when similar white institutions were closed to African Americans.

Even today, the barbershop remains a vital venue to the African American community as a gathering place to debate the issues of the day. “The barbershop is a forum for people to meet and discuss. They come here and say whatever they want to say. They’re free when they’re [here],” says barber Austin Wilfred at Headmaster Barber Shop in Los Angeles.

In both the 2008 and 2012 elections, barbershops played a crucial role in President Obama’s grassroots initiative to register black voters. Political operatives saw black barbers and beauticians serving the same role as black ministers outside the church, leading their “congregations” in electoral campaigns.

Reaching African Americans, particularly low-income men, has traditionally been a challenge for healthcare workers. Mobile clinics have been used for decades in inner city neighborhoods but are patronized in higher numbers by women, according to Victor. Similarly, black churches have developed programs for medical screening and outreach but women are also more likely to be regular churchgoers than men. Sporting events have had limited success as well, providing an inauspicious environment for a frank discussion about health.

There have been other efforts that use the barbershop as a site for health education, typically focused on HIV/AIDS prevention in cities such as Memphis and Atlanta. The Centers for Disease Control and Prevention run an initiative, Business Responds to AIDS (BRTA), that teams with private businesses to promote HIV and AIDS education. A large part of that effort focuses on black barbers and beauty professionals as a conduit into that community.

However, Victor’s studies are the first initiatives that train barbers to do the initial medical screening rather than partnering with local healthcare workers. In many ways, barbershops are the ideal location for medical outreach—they have a large and frequent customer base. “Barbers are trusted peers. They have a lot of respect in their community, more than healthcare workers,” Victor says.

In addition to loyal clientele and a privileged position within the African American community, Victor sees other benefits to using the barbershop as a venue for hypertension intervention. “The chair is perfect for measuring blood pressure,” explains Victor, who cites the high, straight back typical of barber chairs. Customers are also relaxed while sitting in the chair, and Victor advises barbers to take clients’ blood pressure at the end of the haircut, rather than when they first sit down.

Victor and his associates are currently writing the training manual to teach barbers how to measure blood pressure. The training also includes a module on the ethics of human research. “Barbers have a good instinct about dealing with customers,” Victor maintains. “We would like them to recruit [participants] but not be coercive or step over the line. They have a good feel for these kinds of issues.”

Victor’s study will also teach the technical aspects of measuring blood pressure, including how to choose the right size cuff, how to get an accurate reading, and how to interpret the results. Customers who have their blood pressure taken will be given a bar coded membership card to track their meetings with their barbers and whether they sought follow-up care with one of the partner health facilities.

Victor hopes that if the study proves to be effective, they can scale the project to a national level. “The idea would be that at the end of the study we develop business models that are sustainable,” he says. With the launch of the Affordable Care Act, there is increased pressure on healthcare providers to find ways to cut costs without compromising quality. Insurance-plan reimbursements are also tied more closely to specific outcomes.

Victor is hoping barbershop blood pressure measurements will eventually be seen as a legitimate enough path for early intervention that insurance plans will want to adopt this model as well. The earlier study concluded that if similar programs were introduced into the estimated 18,000 black barbershops in the U.S., it would result in 800 fewer heart attacks in the first year, 500 fewer strokes, and 900 fewer deaths.

It’s not hard for both customers and barbers to see the benefits. Basil Hewitt, an engineer getting a trim on a recent Sunday at LA’s Headmasters, saw the upside immediately. “It’s pretty cost-effective if you can get to people where they’re at,” he says. “In the long run, we’re all paying for these health consequences so if we can get to it early, every American is going to save money.”