The Doctor Is In

Stephen Thomas loves barbershops.

For him, as for so many African-American men, they are a place of historical and cultural relevance. In the 19th century, some barbershops doubled as abolitionist sites or stops on the Underground Railroad. In other shops, wealthy white men made business deals while slaves cut their hair. Today, with a clientele that is likely to consist of rich and poor, black and white, laborer and boss, the barbershop occupies a singular station in modern society, the communal gathering place where customers not only get groomed but play games, talk sports, listen to music, watch TV, share stories, and live their lives.

“You can have a judge seated next to a guy who works on a loading dock at Safeway who has a homeless man seated on his other side,” says Thomas, the director of the Maryland Center for Health Equity at the University of Maryland’s School of Public Health. “There is no other venue where you have such a ranging socioeconomic spectrum. A barbershop is a gem. It’s only when you get exposed to it that you can realize how amazing it is.”

And Thomas has figured out a way to harness the power of barbershops to improve the health of their employees and customers, especially those who might not have access to regular healthcare. In 2015, Thomas introduced the HAIR program to the Washington, D.C., area. HAIR stands for Health Advocates In-Reach and Research, an initiative in which healthcare providers work with barbers to improve the barbers’ health and train them to be health advocates for their customers. The goal is to prevent diseases, such as colon cancer, among the shops’ mostly African-American clientele.

While the health outcome data are largely anecdotal at this early stage, Thomas believes HAIR’s experience has proven that a collaboration between academia, small businesses, healthcare providers and insurers can improve people’s health. Surely lessons can be learned from HAIR about improving the health of any high-risk, underserved population.

An Unmet Need

Colon cancer is the third most common cancer in the nation, with more than 97,000 new cases diagnosed each year. It hits African Americans particularly hard. On average, blacks are more likely to develop colon cancer than whites and to develop the disease at an earlier age. And their mortality rate is higher. They are less likely to get screened for colon cancer, even though screening can lead to quicker diagnoses and better outcomes. This means raising awareness is critical among African Americans, says Cara Reymann, chief marketing officer and director of practice development at Capital Digestive Care, one of the largest private gastrointestinal practices in the country and part of the HAIR program.

“We’ve always had a strong interest in advocacy, especially around colon cancer, because it is one of only two cancers that can be prevented through screening,” Reymann says. (The other is cervical cancer.) “We can detect abnormalities that can become cancerous, and if you remove them, you can prevent the cancer from forming in the first place.”

There are a lot of barriers that keep African Americans from getting colonoscopies, including less healthcare access and a fear surrounding the screening process. “They think, ‘Why would a man want to do that to me, even if he is a doctor?’” Thomas says.

Why Barbershops?

In 2001, seeking to reduce health disparities, the Department of Health and Human Services launched a public health campaign encouraging African Americans to establish medical homes for needed healthcare. A number of African-American communities across the nation hosted Take a Loved One to the Doctor days. But Thomas, who worked at the University of Pittsburgh’s Graduate School of Public Health at the time, realized this wouldn’t be effective in communities where a majority of the people weren’t seeing doctors already. So he countered with a Take a Health Professional to the People day. He looked to barbershops because of their trusted position in communities as well as the unique client interactions.

“People in barbershops and salons are there for long periods of time,” Thomas says. “No self-respecting black barber will say, ‘I’ll get you in and out in 10 minutes.’ They are in rest mode, and that hanging out makes it the perfect venue.”

Barbers also have roles as ad hoc consultants on all kinds of issues for their clientele. Thomas was in a barbershop once when a man walked in who had recently left the hospital after suffering a heart attack. After discharge, the customer was given medications, which he pulled from his pocket in the shop and showed everyone.

According to Thomas, the barber looked at the man and said, “If you take those pills, you won’t be able to keep up your obligations.” He was referring to a common side effect of the medication: erectile dysfunction.

“I looked at that man’s face and knew immediately he wasn’t going to take those pills; the barber has that much sway,” Thomas says. “A doctor can write a prescription, but what happens when people get home and talk with these opinion leaders in the community? They don’t have PhDs or MDs, but they have trust that conveys credibility that health professionals themselves don’t have.”

Thomas realized that health information was already being disseminated in barbershops and norms were being shaped—but not always the best kind. He sought to bring an “ecosystem of wellness” to these spaces.

The barbershop program was born after he gave a presentation in Philadelphia about health disparities in the African-American community. At the end of a long line of people waiting to talk with him afterward was Christina Stasiuk, Cigna’s national medical director for health disparities. After talking with Thomas, Stasiuk spent time looking into his work. A year later, the program came to fruition with the help of the Cigna Foundation’s World of Difference Grants, which the insurer gives to nonprofits to improve health opportunities in their communities.

Thomas began with three barbershops in Pittsburgh hosting 10 health professionals who offered screening and information to clientele. By 2008, the program had grown to amass 10 shops with more than 200 healthcare providers. At one point, they screened 700 people in one day. Many of the clients were in such poor health they were sent directly from the barbershop to the emergency room. “That’s how prevalent the morbidity is in these communities,” Thomas says.

Barbers as Advocates

In 2010, Thomas and his entire research team were recruited to the Washington area to launch the Maryland Center for Health Equity. He says they immediately began working on community engagement, research and infrastructure needed for another barbershop program. He reached out to local clinical partners, including the Center for Health Equity and Wellness at Adventist HealthCare and Capital Digestive Care, and received funding and support from Cigna. The D.C. program focused on raising awareness of colon cancer screenings in barbershops and reducing obesity in area salons. There were essentially two parts to the initiative: improving the health of barbers and then training them to provide health information to their clients.

Thomas says when he reached out to local clinical partners like Adventist and Capital Digestive Care, they were eager to get out of their offices and into the community. The first gastroenterologist to go into the shops in D.C. was an African-American woman, which surprised the barbers and their customers.

“They were like, ‘This is what a gastroenterologist looks like?’” Thomas says of the barbers, who proceeded to braid her hair and talk with her about all kinds of health-related issues. “It completely melted away any fear they had of the process.”

The first goal of the program was to work with barbers and improve their health however possible. Roberto Rubio, senior program coordinator and coach for Adventist HealthCare, says Adventist healthcare providers went into the shops each week and offered health screenings and education. They checked each barber’s blood pressure, body mass index and carbon monoxide levels (many of the barbers were smokers). Then they provided information on different topics for them to educate their clients, particularly focusing on colon cancer and other areas of concern for African-American men.

“It’s about building trust in a community of need,” says Marilyn Lynk, director for the Center for Health Equity at Adventist. “These barbers could really be advocates. They could talk about how they did this themselves, how their blood pressure was high and now how eating better or taking medications improved it.”

Rubio conceded that it took a little time for the barbers to get comfortable having healthcare providers in their shops, but they did over time. They even helped the barbers get insurance. Because many are self-employed, they didn’t have coverage and hadn’t been to a doctor in a while.

The providers began by frequenting the shops on a regular basis. Over time, they went less as they saw greater health knowledge and positive health results among the barbers. Many barbers cut back on smoking, and there were improvements in blood pressure and body mass index among them.

“We wanted to prepare the barbers with healthcare knowledge and let them know it was important to talk to clients so barbershops could become health portals where clients could come in and discuss these issues,” Rubio says.

Julia Huggins, vice president of U.S. markets at Cigna, says the simplest part of the equation was teaching the barbers to engage their clients. They already talk about how their kids and family are doing. And it was natural for a barber to engage a client in a conversation about how his health might be affected if the man’s father had recently passed away of something like colon cancer.

“We tapped into a resource that is already viewed as a trusted advisor,” Huggins says. “We didn’t have to teach them to force the conversation; we just had to arm and train the individuals with the right information to provide.”

But the healthcare providers walked a fine line regarding the kind of training that was passed along to clients. Capital Digestive Care’s Reymann says they were careful not to make the barbers surrogates for doctors. Initially, Thomas says, the providers referred to the trained barbers as health advisors but changed that title to health advocates. They didn’t want someone in a health crisis looking to their barber for answers.

A Whole-Body Approach

It was clear relatively early in the HAIR program that health information and screenings had to go beyond colon cancer. The populations in the Washington communities where the barbershops were located mirrored those across the country.

Data show that African Americans are much more likely to die from heart disease and stroke than their white counterparts. They are also more likely to have high blood pressure and diabetes—and all of these at earlier ages. They are also more likely to die younger of any cause than are white Americans.

The healthcare providers ended up screening and educating barbers on issues including alcohol consumption, nutrition and obesity. They also brought in mental health counselors to work on stress management and unresolved trauma.

Lynk says many of the screenings showed the barbers were at high risk for chronic conditions or unknowingly had them already. Lynk’s group provided information on diabetes management and heart disease, got barbers connected with a primary care provider and discussed healthy eating habits and weight loss. “We tried to be culturally sensitive and find ways to align with the cultural norms or resources in their own neighborhoods,” Lynk says.

Pharmacists, Thomas says, were “big hits” in the shops. One shop held a Brown Bag Day during which the pharmacists encouraged people to bring all the medications they were using or were administering to others as caregivers. Participants talked to the pharmacists about side effects and interactions and how to be better advocates for their own health.

A team from the Mayo Clinic visited one of the shops and performed echocardiograms with laptop devices. Nurse practitioners drew blood to check for prostate-specific antigens (used to identify prostate cancer) and performed digital rectal exams (for which the shop had to be temporarily renovated to create a private space).

“Providers are able today to do so much work outside of the office. All kinds of things are possible,” Thomas says. “The miniaturization of diagnostics equipment means they no longer need to be tethered to a hospital or clinic.”

Creating Healthy Partnerships

Huggins says Cigna feels obligated to be part of improving health in communities where its employees live and work. And part of that is working with under-resourced areas and understanding how cultural differences may impact health outcomes among various groups.

“We have to reach certain communities in ways they can understand and take the information and implement it in their own lives,” she says. “Cultural differences are important, and traditional ways of communicating don’t always reach who we are trying to impact. The HAIR program was geared toward the African-American community, where there are some perceptions and misconceptions of illness and the need for screening.”

Huggins sees the role of health service organizations, such as insurers, as conveners for programs such as HAIR. When Thomas’s organization was looking for a partner to help initiate the program, it aligned with Cigna’s desire to promote and deliver screenings and health information in a new and engaging way. Their wide reach and plentiful data can be leveraged to reach out in areas of need.

For example, Huggins says they knew colon cancer was one of the deadliest cancers among African Americans, who were not receiving sufficient education and care.

“We need to make sure we enable partners in the communities to take advantage of our data and tools and knowledge and deliver resources or programs in a way that the communities own them,” Huggins says.

“People won’t be receptive to an entity coming in and telling them what to do. We have to enable them with whatever resources they need because they understand the culture, linguistic barriers and other components that a company is far removed from.”

The success of the HAIR program and others in which Cigna has taken part have reinforced her belief that these partnerships are the right kind of outreach opportunities—and that Cigna’s resources are being delivered where and how they are needed.

Capital Digestive Care has long served as a resource for communities lacking good healthcare services. Reymann says the organization jumped on board because they saw HAIR as a unique way to approach what they knew was a significant issue in the community.

Reymann participated in planning calls to determine the educational materials and other resources necessary prior to the program’s launch in D.C. As part of Capital’s mission, the providers there volunteer for education and community events and serve as a resource for patients who need screening. Barbershop clients they find to be at risk and who have health insurance are further screened in their offices. If clients don’t have insurance, Capital’s providers are able to direct them to local nonprofit healthcare organizations that can provide education and perform the tests.

And it’s not just the communities that are benefiting from providers’ outreach. Health professionals, who are predominately white, can also benefit from working in communities different from their own, learning to educate and screen high-risk populations.

“It helps their competency and confidence reaching settings outside of the hospital,” Thomas says. “And it’s my observation that the doctors really like it. It’s a win-win all the way around.”

Duplicating the Efforts

Insurers and public health groups clearly believe in the possibility of population health management to improve health outcomes. Businesses, too, can consider looking at innovative ways to work with their own organizations to improve health and, in turn, better control costs.

Reymann says the most important tool a self-insured employer has is working directly with a provider for preventive services. “It’s a trend we are seeing on a national level, but there’s not enough of it,” she says. “The downstream effects of prevention instead of treatment are so great.”

Employers can engage directly with providers and negotiate for lower costs or bundled rates. They can start by working with whoever holds the data, which could be the insurance company or third-party aggregators, to determine what an employee population looks like from a health perspective. Screenings and personal health histories can help gauge areas of need.

Employers can use creative tactics like giving gift certificates for completing health histories, offering paid time off when employees get a physical, or a day off for a more complicated test, like a colonoscopy.

Lynk recommends working with as broad a group of stakeholders as possible to identify and treat where need and disparities exist in a population. These can include the business community, faith-based organizations or local health departments.

There are likely hospitals in most places with missions and dollars to do outreach, education or screenings to improve their communities’ health. When thinking about investing, she says, most hospitals want to see data to identify issues of concern in the community and work there to improve outcomes. Adventist, for example, partners with groups to deal with community issues like education, housing, air quality and food insecurity.

Barbershop Expansion

Thomas has big dreams to expand the barbershop program. His first goal is to create a nationwide group, the National Association of Black Barbershops and Salons for Health, which would enroll barbershops and salons that want to be involved in the health arena.

“We want to make sure they are open, ready and willing to disseminate evidence-based health information and are able to have professionals come in and provide screenings,” he says.

Thomas is using his anchor shop in the D.C. area to test out new ideas. There, flat-screen TVs hang on the walls. On the HAIR wall, the TV doesn’t show sports or Judge Judy, but rotates health information. Nearby is a shoebox where people can submit health questions, which his staff answers and turns into infographics. Thomas wants to be able to deploy the messages to all barbershops taking part in HAIR.

He’s working with a technology company to create a smart phone app called My Barbershop Buddy. The app will provide and track health information of barbers and their customers who are served by HAIR. He even has dreams of creating a smart barbershop chair where people getting haircuts can plug in their phones and download information they have tracked, including their weight, food intake or steps walked.

“This is an innovative, outside-the-box strategy for reaching high-risk populations,” Thomas says. “We can have health professionals available in barbershops, and to get there we need partners like Cigna who are willing to invest in these kinds of crazy ideas—ones who recognize that, at the end of the day, they are paying the bills.”