Shop Talk: A Qualitative Study to Understand Peer Health-related Communication Among Black Men at the Barbershop

Abstract

Background

While successful health promotion efforts among Black men have been implemented at barbershops, the focus has largely been on outcomes as opposed to the processes by which outcomes are produced. An understanding of processes can be leveraged in the design and implementation of future efforts to improve the health of Black men.

Purpose

The objectives of the present study were to: (i) understand peer-derived sources of health-related support at the barbershop and (ii) understand the role of the barbershop in promoting health among Black men.

Methods

Seven focus groups were conducted at barbershops used predominately by Black men. Each focus group lasted between 45 and 60 min. Using a thematic approach, each focus group was independently coded by two coders using a codebook derived from an inductive and deductive approach. The results were confirmed with members of the community advisory board.

Results

Three themes emerged: (i) dynamic and candid exchange of health-related support at the barbershop; (ii) tailored forms of health-related and judgment-free communication that provide encouragement and increase motivation; and (iii) characteristics of a supportive environment at the barbershop that facilitate health-related communication.

Conclusions

The findings of the present study offer a potential pathway for public health efforts seeking to improve health among Black men. Those interested in designing and implementing these efforts can create tailored programs for Black men by recognizing and leveraging the unique dynamics of health-related conversations at the barbershop.

Black men find dynamic, candid, and judgement-free health-related support in barbershops, highlighting the potential of these spaces to promote health through tailored programs that leverage their unique environment.

Introduction

Black men demonstrate determination in the face of numerous adversities. Despite experiencing constant burdens of systemic racism, economic disparities, and unequal access to opportunities that impede health promotion [1, 2], qualitative research conducted among Black men unanimously indicates that these men value their health [3–5]. It is therefore concerning that Black men have among the lowest life expectancy of any racial/ethnic-gender group in the USA (e.g., Black men live 13.3 years less than Asian men, 7.3 years less than Hispanic males, and 7 years less than non-Hispanic White males) [6]. Driving this low life expectancy are high rates of health concerns such as heart disease [7], diabetes [8], hypertension [9], and prostate cancer [10]. These health disparities are not only a public health issue, but they are also a matter of social justice. The incongruence between qualitative research conducted among Black men indicating that these men value their health juxtaposed with the alarming rates of premature mortality and health concerns among these men underscores the urgent need for a robust understanding of how to align health promotion efforts to the preferences, values, and perspectives of Black men. This alignment is known to improve recruitment, retention, and meaningful health-related change among Black men [11, 12].

The Health, Illness, Men, and Masculinities (HIMM) Framework asserts that there is a need to understand men’s health and illness practices in the larger social context of masculinity [13]. The HIMM Framework redirects the emphasis of comprehending men’s health and health promotion from the individual level to the broader sociocultural concept of masculinity. It recognizes masculinity as a structural context that shapes and perpetuates health knowledge, attitudes, and behaviors through socially constructed gender norms [14, 15]. For example, men’s internalization of traditional masculinity has been associated with healthcare utilization [16], risk-taking behaviors [17], and risky sexual behavior [18]. Although the adverse impact of these health views and practices are well documented and ubiquitous in the men’s health literature, they are modifiable [19]. Efforts to improve health among men may benefit from being attentive to masculinities [20–22]. Research indicates that gender-sensitive and gender-transformative interventions are effective for promoting health among men [23, 24]. These interventions often utilize existing social networks to promote health among men [2] to shift masculine norms by giving men permission and affirmation to discuss private health concerns [25].

Social networks serve as an important context for the exchange of ideas, beliefs, and behaviors among peers. Many successful health promotion efforts among men have capitalized on the importance of peer support [26, 27]. It has been found that peer social control (e.g., interactions between peers that entail regulation, influence, and constraint) can serve as a catalyst for positive health behaviors and lifestyle changes among men [28]. That is, engaging with peers who prioritize health promotion can inspire men to adopt healthier habits. A comprehensive systematic review found that interventions leveraging peers have facilitated meaningful changes in a wide range of health outcomes, including physical activity, smoking, and condom use [29]. Because peers share a common language, culture, and knowledge, these models of health promotion can be adapted to align with the values of Black men [30]. There has been a considerable amount of research conducted among Black men that supports the importance of peers—Black men prefer to rely on informal sources of social support when addressing health concerns [31–36]. The importance of peers among Black men is underscored by the success of health promotion interventions conducted among these men that have leveraged peers [11, 37].

The barbershop is a place of cultural significance for many Black men. Barbershops are a safe place for Black men to engage in conversations and seek advice from peers who may share similar life experiences. These barbershops serve as de facto informational hubs for many Black men, providing valuable knowledge about health concerns, strategies to promote health, and community resources [38]. In addition to promoting health, barbershops have other historical contributions to the Black community such as being one of the first venues for Black prosperity and entrepreneurship [39]. Recently, academic health promotion specialists have noted the importance of barbershops for Black men and have implemented successful health promotion efforts at these sites [37, 40]. These efforts have been successful at improving a wide range of health outcomes, including blood pressure [41, 42], prostate cancer knowledge [43, 44], and unprotected sex [45].

Although the unique successes of barbershop-based interventions have been growing in the academic literature, it should be recognized that barbershops have been the sites of health promotion efforts among Black men for generations [38]. Comprehensive reviews have been published on the impact of health promotion efforts based in barbershops [37, 46–48]. Although these reviews provide support for the success of barbershop-based efforts among Black men, there remains a significant gap—these reviews address what has been successful (i.e., barbershop-based health promotion efforts) as opposed to how these efforts have been successful. Health promotion efforts in barbershops remain a “black box.” That is, there is a need to understand the processes by which outcomes are produced to leverage these processes in the design and implementation of future efforts [40, 49].

There is robust theoretical support to justify a nuanced understanding of peer-based health promotion efforts among Black men at the barbershop. Social Learning Theory, Social Cognitive Theory (SCT), and Communication of Innovations Theory have all been used to justify these peer-based health promotion efforts [50, 51]. SCT is an extension of Social Learning Theory and posits that health-related learning occurs in a social context. Central to SCT is reciprocal determinism—the idea that there is a dynamic relationship between the individual, their environment, and their behavior [52]. SCT underscores the significant role of peer communication in shaping behaviors and attitudes, highlighting that individuals learn not only through personal experience, but also by observing and mimicking the actions, reactions, and outcomes of their peers. Communications of Innovation Theory (later known as Diffusion of Innovation Theory) seeks to explain how an idea (e.g., a health concern or behavior) spreads among a group [53]. Central to this theory is the notion that there are early adopters of a behavior within a group and that these early adopters influence others within that group to also adopt that behavior. The adoption of new behaviors is facilitated through communication, such as with peers.

Understanding the dynamics of the social context and how individuals influence one another at the barbershop may shed some light on the “black box” of barbershop-based health promotion efforts. This understanding can facilitate health promotion efforts and lead to meaningful outcomes. Despite the success of peer-to-peer and barbershop-based health promotion efforts among Black men, in addition to the strong theoretical support used to justify these interventions, there is a lack of in-depth research on how men communicate and provide peer support and encouragement to one another in the barbershop. A greater understanding of how men communicate at the barbershop can be leveraged in future efforts. The objectives of the present community-based participatory research (CBPR) study were to conduct focus groups to (i) understand peer-derived sources of health-related support at the barbershop and (ii) understand the role of the barbershop in promoting health among Black men.

Methods

Collaborative Stakeholder Engagement

This project emerged as a result of a community-academic partnership between the Principal Investigator (PI) and various stakeholders. Before initiating the project, the PI engaged in discussions with a community organizer, who provided support for the project and connected the PI with a men’s group associated with a predominately Black church. The project was presented to the men’s group and their unanimous support solidified the foundation of the present project. Although the PI initially proposed to conduct the present study at predominately Black churches due to previous collaborations with Black churches [54], the men from the men’s group indicated that it should occur at barbershops because there would be greater age diversity at barbershops compared to churches. Subsequently, a community advisory board (CAB) was formed, comprising Black men from the local area, including a Pastor, State Representative, community organizer, and a barber. The CAB members were compensated $20 per meeting for their input.

Interview Guide Development

An iterative process was employed to create the focus group interview guide. The process involved multiple meetings among the PI, academic partners, and the CAB to discuss the interview guide. The PI also sought input from a group of barbers to ensure the acceptability and relevance of the focus group questions. These barbers were compensated $30 for their contributions.

Data Collection

In adherence to ethical guidelines, the project received institutional review board approval from a large university in the Southeastern USA where the PI is employed. The PI leveraged the knowledge and assistance of the CAB to identify barbershops frequented by Black men and then the PI approached the shop owners to gauge their interest in participating in the project. If interest was acknowledged, the PI sent out recruitment flyers to the barbershop. The owners were informed they would receive $100 as compensation for hosting a focus group and helping recruit eligible customers for participation. To be eligible for the study, participants had to self-identify as African American or Black males, be between the ages of 18 and 90, and be fluent in English. Focus groups were scheduled once 8–10 interested men were identified by the barbershop owners, with the timing of the sessions accommodating the participants’ schedules. Each focus group, led by the PI, lasted between 45 and 60 min, and participants received $40 as compensation for their time and contributions. All focus groups occurred in a small metropolitan area of South Carolina that serves a large rural population. Data collection ceased after seven focus groups, which was when saturation (i.e., no new information was uncovered) was reached. Audio recordings of each focus group were professionally transcribed.

Data Analyses

Data analyses were conducted using Dedoose (i.e., a qualitative data analysis program). Dedoose was used because it is web-based and it allowed the co-investigators to collaborate at a distance. The development of the codebook drew upon both deductive and inductive approaches [55]. An initial set of codes was established based on existing qualitative research among Black men [56–59] and further refined by an inductive approach derived from immersion in the data. Two experienced individuals, familiar with qualitative data collected among Black men [60], independently coded each transcript and resolved discrepancies through discussion, achieving 100% agreement. A thematic analysis was then performed to derive meaning from the results [61]. Themes were identified based on codes that appeared in over 50% of the focus groups and were then confirmed with the CAB, ensuring the validity and reliability of the findings. See Supplementary File for a visual map of data analyses and coding process.

Results

Sample

The sample of the present study consisted of 56 Black men across seven focus groups. The mean age was 45.28 years (SD = 12.77) and approximately 70% of participants had a high school education or less. See Table 1 for additional demographic information.

Table 1.

Demographic Information

	N (%)
Race/ethnicitya
American Indian or Alaska Native	3 (5.36%)
Caucasian/White/European American	1 (1.79%)
Education
Less than high school	8 (14.29%)
High school or GED	31 (55.36%)
Some college	3 (5.36%)
Trade/technical school	6 (10.71%)
2-year college	4 (7.14%)
4-year college	2 (3.57%)
Professional/graduate school	1 (1.79%)
Annual salary
Less than $10,000	22 (39.29%)
$10,000–$19,999	6 (10.71%)
$20,000–$29,999	6 (10.71%)
$30,000–$39,999	4 (7.14%)
$40,000–$49,999	4 (7.14%)
$50,000–$59,999	1 (1.79%)
$60,000–$69,999	1 (1.79%)
$70,000–$79,999	1 (1.79%)
$80,000–$89,999	1 (1.79%)
$90,000–$99,999
More than $100,000	2 (3.57%)
Marital status
Married	9 (16.07%)
Unmarried couple	1 (1.79%)
Single	38 (67.86%)
Divorced	1 (1.79%)

^aRace/ethnicity in addition to Black/African American.

Themes Derived from Focus Groups

See Table 2 for a summary of the themes and supporting codes derived from the data. Three themes identified were (i) dynamic and candid exchange of health-related support at the barbershop; (ii) tailored forms of health-related support that are marked by encouragement, judgment-free communication, and motivation; and (iii) characteristics of a supportive environment at the barbershop that facilitate health-related communication.

Table 2.

Summary of Themes

Theme	Supporting codes	# of focus groups appeareda
How do Black men communicate health-related information at the barbershop?
Theme 1: Dynamic and candid exchange of health-related support at the barbershop	Talking	6
	Listening	7
	Role modeling	6
	Passing of wisdom	4
	Passive testimonial	4
	Calling out	4
What do Black men communicate when they discuss health-related information at the barbershop?
Theme 2: Tailored forms of health-related support that are marked by encouragement, judgment free communication, and motivation	Tailored information	5
	Encouragement	4
	Judgment free	4
	Motivation	4
What about the barbershops facilitate health-related communication?
Theme 3: Characteristics of a supportive environment at the barbershop that facilitate health-related communication	Inherent conversations	7
	Presence of peers	7
	Positivity	6
	Mental health promotion	6
	Social support	6

^aThe maximum number of focus groups was 7.

Theme 1: Dynamic and candid exchange of health-related support at the barbershop. Participants were asked how Black men communicate health-related information in the barbershop. This theme represents the reciprocity of health-related information that occurs at the barbershop and represents how Black men communicate about health. Participants in almost every focus group discussed the roles of talking, listening, and role modeling in communicating about health at the barbershop. They also discussed the importance of a general passing of wisdom and passive testimonials. For example, these men discussed the importance of peers and learning from peers about health:

"I guess listen to each other vent. Only person who gonna understand your problems is another person in your situation, you know what I mean?"

They also discussed that health-related knowledge is conveyed through the passing of wisdom—the generational transmission of health-related knowledge from older individuals with lived experiences. At times, participants indicated a preference for this form of health-related communication over formal forms of medical advice (e.g., seeing a doctor):

"If somebody has a problem and you talking someone older, and you know, sometimes that older gentleman pass down the wisdom that he had dealing with that certain situation, you know, like his heart. So it could be high blood pressure or anything like that, they’ll tell them to drink more water. Stop eating all the salt, stuff like that."

"Like as far as if I got something wrong. I’ll ask an old gentleman [at the barbershop] before I go to the doctor."

Interestingly, conversations at the barbershop, and the way health information is communicated, had indirect ripple effects through passive testimonials. Participants indicated that even though they were not directly involved in a particular conversation, they still reaped benefits from that conversation:

"But you hear another guy talking about something and you’re like, oh I should do that, like I should drink more water, I should do whatever that is."

"We were sitting in here years ago, this was well below five years, longer than that. We were sitting in the barber shop, having conversation, some other mens and the gentlemen, he sat over there in the corner and he was just quiet. Quiet, hadn’t said a word, come to get his hair cut. And we was talking and then I got him in the chair and he got up and he said thank y’all, cause the conversation was going on in here helped me. It helped me a lot cause I was getting ready to do something, something that I most likely would have grown to regret, but listening to y’all conversation, it helped me. It helped me out a lot. So we didn’t ask him what he was going to do or what."

Finally, it is noteworthy that although participants generally regarded these health-related communication strategies as helpful, they drew attention to areas for improvement. Specifically, participants mentioned the need for more communication:

"We don’t communicate, we don’t know how to talk to each other. So some of these things got to be implemented so we need positive role models."

In addition, the men drew attention to efforts to curb the spread of health-related misinformation, as reflected in the exchange below:

"Participant 1: Cause he said he need turpentine, I’m thinking like what are you going to do? You going to drink it? You going to soak your feet in it.

Participant 2: Yeah, what.

Participant 1: But I’m not going to try it. That’s where his mind at. That was bad advice to me.

Participant 2: Y’all like, I don’t want that.

Participant 3: See that probably come from an old family remedy though."

Theme 2: Tailored forms of health-related support that are marked by encouragement, judgment-free communication, and motivation. This theme represents the impact of health-related communication between peers that occurs at the barbershop. It represents what Black men communicate when they discuss health at the barbershop. Participants in almost every focus group discussed the importance of receiving individually tailored information, encouragement, judgment-free advice, and motivation at the barbershop. For example, the importance of tailored information can be seen in the following passage:

"Participant 1: The preacher is talking to everybody. Your barber is talking to you….

Participant 2: He talking to you, he ain’t talking to everybody.

…

Participant 1: And you know, he [the barber] don’t talk to everybody the same conversation.

…

Participant 1: That conversation he’s talking to you is your conversation. Conversation he talking to him is his conversation. You know, every conversation is different. Every conversation is not the same with everybody."

The participants also indicated that peer health-related conversations at the barbershop were characterized as being encouraging, judgment-free, and motivational. For example:

"He’ll [another man at the barbershop] tell you the right thing, he encourages and hope."

"Nobody judge nobody … how’s your day going? Well, man, it’s messed up, okay, well, you know. It can be better, he’ll [another man at the barbershop] give you a piece of advice well, you know, might need to get some more rest at night time. You know, nobody judge nobody, nobody said, man you need to be doing this or do that. They give you suggestion; well, I remember this, I remember how this was, you know."

"Like I motivate me I guess, you can say, like usually if I’m by myself I’m like a closed off person, I don’t really talk to no one else. Well, with them [peers at the barbershop] they force me to speak, you know, like I can speak to them without them, knowing they won’t judge me and stuff like that. Probably they won’t sit there like, here he goes again, you know, they actually listen and give me solution."

Theme 3: Characteristics of a supportive environment at the barbershop that facilitate health-related communication. This theme highlights the characteristics of an open and supportive environment at the barbershop that sets the stage to facilitate Themes 1 and 2. When asked “what role does the barbershop play in influencing health among Black men?” the participants responded that conversations, the presence of peers, positivity, social support, knowledge, and mental health support were important. The participants drew attention to the inherently social nature of the barbershop:

"And then the conversation, I mean, it won’t be, like a dull moment sitting in the chair and just talking. And then you hear barbers from left and right. Everybody’s enjoying the conversation, just the barber shop; it’s the place if you ask me."

"Well, the barber shop, I think people come sometimes and get their hair cut at the barber shop, not only for a haircut, just to socialize and get a peace of mind, to talk, to smile, to laugh, you know, talk about the game, you know, that takes a lot off of you. You know, stress, you worried about paying a bill, you know, you come to the barber shop, we get in to talking about the game, you know, and our surrounding areas and what they’re doing, and that takes a lot of stress and, you know, you’re being social with everybody. And, you know, that’s, you enjoy that cause I enjoy when people just coming in and, you know, we sit down and talk and we have conversation, you know, it’s, really, I enjoy it. Just talking to people about different things, you know, that, some of the issues going on in their life, how to do things, and it means a lot. You come by the barber shop and connected with your barber."

Participants unanimously indicated that the social aspect of the barbershop was marked by positivity:

"Yeah, we talk about everything, you know, we don’t do it—cause one thing I noticed about [the barber] if you start getting on some negative shit he’ll veer off to something positive. You know, he don’t have the time to listen to no negative stuff. You know, he going to try his best to make it seem more positive than negative."

"It’s the positive energy and the atmosphere and just the people that socializing. It makes you feel welcome."

Participants also noted that the social aspect marked by positivity was linked to positive mental health:

"Participant 1: You liven up, you get happy.

Participant 2: You walk in here you got the music playing loud, you have the music playing. I mean, you get a vibe; you make friends.

Participant 1: It’s the Black men it’s the camaraderie."

"Yeah, like today, my day, I came in here this morning at 7:30 8:00 o’clock this morning I was here getting my son haircut. Went home and had a nice good personal positive attitude about everything today."

Discussion

Health promotion efforts among Black men have been limited in impact. These efforts often exhibit difficulties in recruiting, retaining, and producing meaningful health-related changes among Black men. Thus, there is a need for health promotion efforts that align with the preferences, values, and perspectives of Black men [11, 12]. This sort of alignment is known to circumvent these difficulties [11]. Many health promotion efforts among men and Black men have directly and indirectly leveraged vicarious learning and modeling via peers to inspire and sustain positive health-related changes [15, 30]. For example, many successful health promotion efforts among Black men have been conducted at the barbershop [37]—a place of cultural significance that has been consistent over time [38]. The barbershop remains one of the few settings where one can reliably access Black men [62]. Barbershops also provide a context for disseminating information to Black men across the life course. Despite the growing recognition of the importance of barbershops by the academic health promotion community, there is a need to understand the processes by which outcomes are produced to leverage these processes in the design and implementation of future efforts.

The results from the present study shed light on how Black men communicate about health at the barbershop and what these men include in those health-related communications. The results also shed light on how to work with and train peer supports to communicate in a manner that encourages health promotion. The findings indicate that Black men communicate about broadly defined health (including notions of well-being) messages at the barbershop through a variety of methods, including venting, passing of wisdom, and passive testimonials. These messages are delivered in ways that signal encouragement, no judgment, and inspire motivation, which aligns with previous qualitative research among Black men indicating that these men prefer holistic messaging [36], positive messaging [63], communication patterns marked by ease [64], and messaging that empowers [65]. Finally, the present study also sheds light on environmental aspects of the barbershop that facilitate the communication of health-related information at the barbershop—the inherently social nature of the barbershop, the positivity at the barbershop, and the barbershop’s impact on mental health promotion. The findings from the present study are noteworthy because there is strong evidence for health promotion interventions among men to be conducted using methods of everyday language and delivered in comfortable community-based settings [66] by peers [15]. Additionally, the specific dynamics and the role of the barbershop environment add a unique layer to the present study. For example, the previously mentioned studies examining health-related communication preferences among Black men may have found similar themes of support and motivation, but the informal and culturally resonant atmosphere of the barbershop enhances these interactions in ways that are specific to this environment and population.

The results indicate that strategies that foster peer-derived sources of support and communication could be leveraged to improve health among Black men. Research indicates that support from trusted sources [67], such as peers, is associated with health promotion motivation among Black men [68]. There was recognition among the participating men that communication between peers about health-related topics is important to health promotion for Black men and that strategies are needed to improve this communication. It is important to note that the results of the present study also highlight that peer-related communication may have health-promoting ripple effect on others. Aligned with intersectionality and the Health, Illness, Men, and Masculinities theoretical framework [13], efforts to improve health among Black men may benefit from being attentive to masculinities [20–22] and gender roles functioning as barriers to health communication [23]. Research indicates that gender-sensitive and gender-transformative interventions (i.e., interventions that seek to transform harmful gender norms) are effective for promoting health among men [23, 24]. These interventions can utilize existing social networks to promote health among men [23] in order to shift harmful masculine norms (e.g., “manning up”; “tough guy syndrome”—an informal term coined by Dr. Harold Neighbors that refers to the preference of many men to avoid appearing weak, or less of a man, by talking about health concerns) [69] by giving men permission and affirmation to discuss private health concerns [25].

The results from the present study should be viewed in light of their strengths and limitations. The evidence of the present study is supported by the study’s foundation in CBPR. CBPR is an approach to research that integrates the priority population in the development, implementation, and evaluation of the research process and is considered a viable strategy to reduce health disparities [70]. The project was developed through consultation with Black men from the community and leveraged the expertise of a CAB of Black men from the area. The findings of the project were confirmed with the CAB. Additionally, the present study included a large number of Black men allowing the focus groups to reach data saturation. It is noteworthy that research among Black men often faces difficulties with recruitment and retention. The use of CBPR and a CAB facilitated the recruitment of an adequate number of participants. A final strength of the present study is the topic—there is limited information focusing on how Black men communicate about health-related topics. Thus, the present study makes a valuable contribution to the literature and can guide future research that incorporates peer support to improve health among Black men. A limitation of the present study is that the focus groups occurred in a geographically limited area (i.e., central South Carolina). Black men in this area may exhibit unique linguistic tendencies not found among other Black men in the USA. This may impact the generalizability of the findings and should be a consideration in future work.

The findings of the present study offer a potential pathway for public health efforts seeking to improve health among Black men. Those interested in designing and implementing these efforts can create tailored programs for Black men by recognizing and leveraging the unique dynamics of health-related conversations at the barbershop. Doing so could align the effort with the preferences, values, and perspectives of Black men—an alignment that can improve recruitment, retention, and the production of meaningful health-related changes [11, 12]. Additionally, these findings have implications for those designing tailored health promotion messages for Black men—a strategy that is considered an important step for achieving health equity [20]. These efforts also hold promise because they are sustainable, cost-effective, and scalable [71].

Supplementary Material

Supplementary material is available at Annals of Behavioral Medicine online.

Funding

Guillermo M. Wippold is funded by the National Institute on Minority Health and Health Disparities of the National Institutes of Health (K23MD016123). Demetrius A. Abshire is funded by the National Institute on Minority Health and Health Disparities of the National Institutes of Health (K23MD013899). The study sponsors had no role in study design; collection, analysis, and interpretation of data; writing the report; and the decision to submit the report for publication.

Compliance with Ethical Standards

Authors’ Statement of Conflict of Interest and Adherence to Ethical Standards The authors have no conflicts of interest.

Author Contributions Guillermo Manuel Wippold (Conceptualization [lead], Data curation [lead], Formal analysis [lead], Funding acquisition [lead], Investigation [lead], Methodology [lead], Project administration [lead], Resources [lead], Software [lead], Writing – original draft [lead]), Demetrius Abshire (Data curation [equal], Formal analysis [equal], Writing – review & editing [lead]), Dawn K Wilson (Methodology [supporting], Writing – review & editing [supporting]), Terry Woods (Resources [supporting], Writing – review & editing [supporting]), Nicole Zarrett (Methodology [supporting], Writing – review & editing [supporting]), and Derek Griffith (Methodology [supporting], Writing – review & editing [supporting])

Study Registration This study was not formally registered.

Analytic Plan Registration The analysis plan was not formally pre-registered.

Availability of Analytic Code There is no analytic code associated with this study.

Availability of Materials Materials used to conduct the study are not publicly available.

Data Availability

De-identified data from this study are not available in a public archive. De-identified data from this study will be made available (as allowable according to institutional IRB standards) by emailing the corresponding author.