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Can Barbers Help Black Men Lower Their Blood Pressure?

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Barbershop trial

Caption: Barber Eric Muhammad (left) in his barbershop taking the blood pressure of patron.
Credit: Smidt Heart Institute, Cedars-Sinai Medical Center

You expect to have your blood pressure checked and treated when you visit the doctor’s office or urgent care clinic. But what about the barbershop? New research shows that besides delivering the customary shave and a haircut, barbers might be able to play a significant role in helping control high blood pressure.

High blood pressure, or hypertension, is a particularly serious health problem among non-Hispanic black men. So, in a study involving 52 black-owned barbershops in the Los Angeles area, barbers encouraged their regular, black male patrons, ages 35 to 79, to get their blood pressure checked at their shops [1]. Nearly 320 men turned out to have uncontrolled hypertension and enrolled in the study. In a randomized manner, barbers then encouraged these men to do one of two things: attend one-on-one barbershop meetings with pharmacists who could prescribe blood pressure medicines, or set up appointments with their own doctors and consider making lifestyle changes.

The result? More than 63 percent of the men who received medications prescribed by specially-trained pharmacists lowered their blood pressure to healthy levels within 6 months, compared to less than 12 percent of those who went to see their doctors. The findings serve as a reminder that helping people get healthier doesn’t always require technological advances. Sometimes it may just involve developing more effective ways of getting proven therapy to at-risk communities.

For Ronald Victor at Cedars-Sinai Medical Center, Los Angeles, lead author of The New England Journal of Medicine study, it all began several years ago in Texas. Victor was principal investigator of the Dallas Heart Study, which enrolled thousands of local residents with the goal of improving the diagnosis, prevention, and treatment of heart disease [2]. Among the study’s participants were many black men with uncontrolled hypertension, putting them at great risk for heart attack, stroke, and other potentially debilitating health problems. Victor also learned that many of them hadn’t seen a doctor in years.

He got to thinking about how he could reach out more effectively and help black men take control of their health. The community advisory board at a local clinic suggested that he try black-owned barbershops. Coincidentally, Victor’s wife had also seen a television segment about an author who had interviewed barbers across the country, including Oprah Winfrey’s father in Nashville, TN.

It was clear that barbershops are a social hub, and many black men trust their barber and remain loyal patrons for many years. Victor wanted to get barbers involved in health promotion, conducting blood pressure checks and encouraging those customers with untreated hypertension to visit their doctors.

In 2006, Victor launched an NIH-funded study in Dallas to test whether barbershop-based health checks could lower blood pressure. To his frustration, the results were pretty discouraging [3]. The men with high blood pressure, upon being referred to their doctors, rarely received prescriptions for more medication or achieved better control [4]. This is a common issue in busy primary care practices where responsibility is shared among patients, doctors, and health systems.  Meanwhile, Victor noticed recent clinical trials showing the effectiveness of pharmacists working in clinics for improving blood pressure in patients [5]. When he moved to Cedars-Sinai, Victor realized what he needed to do was to combine health promotion by barbers with rigorous, blood pressure drug therapy delivered by pharmacists.

In the new NIH-funded study, Victor and his colleagues, including barber Eric Muhammad (in the photo), enlisted 52 black-owned Los Angeles barbershops. Each barbershop was randomly assigned to either the pharmacist-led intervention in which barbers encouraged meetings in barbershops with pharmacists who could prescribe an intensive two- or three-drug therapy or the control group. In the control group, barbers encouraged customers with high blood pressure to pursue healthy lifestyle changes and see their doctors.

At the start of the study, all participants had a systolic blood-pressure level of 140 mm Hg or higher on two separate days, indicating they had high blood pressure. In fact, the average systolic blood pressure was about 152 mm Hg. Systolic blood pressure is the first number in a typical blood pressure reading. It measures the pressure in the blood vessels when the heart beats. A healthy blood pressure is now defined as below 130/80 mm Hg.

At 6 months, patrons of barbershops assigned to the pharmacist-led intervention had reduced their systolic blood pressure by 27 mm Hg on average to less than 126 mm Hg. In contrast, patrons of the control barbershops, who received treatment from their usual doctors, lowered their systolic blood pressure by only about 9 mm Hg to about 145 mm Hg. More than 63 percent of participants in the intervention group ended the study with a healthy blood-pressure level of less than 130/80 mm Hg. There were also no serious treatment-related adverse events.

Victor said that in addition to more intensive drug therapy, there are likely several reasons for the intervention’s success. The pharmacists made it convenient for men to access the needed treatment. But, he said, you can’t overestimate the value of the barbers and their strong endorsement of the program. It’s not uncommon for barbershop patrons to visit the same barbers every other week for a decade or more. That consistency also made it much easier for patrons and pharmacists to manage their new hypertension medications.

The study is now being extended for another 6 months to see how well the observed improvements in blood pressure are maintained. The research team is also gearing up to expand the study to more cities around the country, including Nashville, home to the Winfrey’s famed barbershop. They will also begin enrolling individuals with milder elevations in systolic blood pressure in the 130 to 140 mm Hg range, which is in keeping with guidelines issued late last year that lower the definition of high blood pressure to encourage earlier intervention and treatment [6]. Victor says he is already speaking with several health systems about potentially adopting this new model as an effective way to reach more patients in need of hypertension care.

These findings are a useful example of the power of programs that reach at-risk populations in their own communities for improving health and reducing health disparities. It’s a lesson we’ll take to heart as more than 1 million people living in the United States will soon begin sharing information about their health with the NIH’s All of Us Research Program to accelerate research and improve health.

References:

[1] A Cluster-Randomized Trial of Blood-Pressure Reduction in Black Barbershops. Victor RG, Lynch K, Li N, Blyler C, Muhammad E, Handler J, Brettler J, Rashid M, Hsu B, Foxx-Drew D, Moy N, Reid AE, Elashoff RM.N Engl J Med. 2018 Mar 12.

[2] Dallas Heart Study. UT Southwestern Medical Center, Dallas.

[3] Effectiveness of a barber-based intervention for improving hypertension control in black men: the BARBER-1 study: a cluster randomized trial. Victor RG, Ravenell JE, Freeman A, Leonard D, Bhat DG, Shafiq M, Knowles P, Storm JS, Adhikari E, Bibbins-Domingo K, Coxson PG, Pletcher MJ, Hannan P, Haley RW. Arch Intern Med. 2011 Feb 28;171(4):342-350.

[4] Differential treatment of hypertension by primary care providers and hypertension specialists in a barber-based intervention trial to control hypertension in Black men. Rader F, Elashoff RM, Niknezhad S, Victor RG. Am J Cardiol. 2013 Nov 1;112(9):1421-1426.

[5] The impact of interventions by pharmacists in community pharmacies on control of hypertension: a systematic review and meta-analysis of randomized controlled trials. Cheema E, Sutcliffe P, Singer DR. Br J Clin Pharmacol. 2014 Dec;78(6):1238-1247.

[6] New ACC/AHA High Blood Pressure Guidelines Lower Definition of Hypertension. American College of Cardiology. 2017 November 13.

Links: 

High Blood Pressure (National Heart, Lung, and Blood Institute/NIH)

Ronald Victor (Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles)

All of Us Research Program (NIH)

NIH Support: National Heart, Lung, and Blood Institute; National Center for Advancing Translational Sciences