Barbers Against Prostate Cancer: A Feasibility Study for Training Barbers to Deliver Prostate Cancer Education in an Urban African American Community

Abstract

The goal of this pilot study was to assess the feasibility of training barbers to deliver a brief culturally and literacy appropriate prostate cancer educational intervention to urban African American men. Eight barbers received training to deliver a 2-month educational intervention in the barbershop and completed pre- and posttest training assessments. The training workshops led to a significant increase in mean prostate cancer knowledge scores among the barbers (60% before vs. 79% after; P< 0.05). The barbers also reported positively on the intervention in terms of satisfaction and relative ease of engaging clients. Training barbers to deliver a prostate cancer educational intervention is a feasible strategy for raising prostate cancer awareness of the disease among a priority population.

Introduction

Based on national data, African American men have higher prostate cancer incidence and mortality, present with more advanced disease, and have lower 5-year survival rates than white men [1]. Due to the epidemiological data and controversies surrounding prostate cancer screening (PCS), it is imperative that African American men have meaningful and accurate information to be able to make informed decisions about early detection. Previous studies have found a correlation between knowledge of prostate cancer and screening behavior [2, 3]. Thus, the use of innovative community channels for disseminating cancer information and awareness are needed for reaching at-risk populations and impacting health disparities.

A number of studies have documented the feasibility of training beauticians and cosmetologists to deliver health messages [4–7]. The barbershop has been proposed as a feasible venue for health promotion efforts for different disease sites; however, few studies have been conducted to evaluate the feasibility of training barbers as lay health advisers to educate men on the topic of prostate cancer [8–11]. Our study goal was to evaluate the feasibility of training barbers to deliver a brief culturally and literacy appropriate prostate cancer educational intervention to African American men. The two study hypotheses are that it is feasible to: (1) develop, administer, and evaluate systematic training workshops for barbers to provide them with the skills to deliver prostate cancer education; and (2) utilize trained barbers to disseminate relevant and reliable prostate cancer education messages.

Methods

Study Design and Recruitment

The study was divided into three phases. In phase I, barbershops were formally identified and recruited, and materials from previously developed prostate cancer education toolboxes tailored for African American men were updated and customized for the barbershop setting [12]. During phase II, training manuals and workshops were developed and administered to barbers. Lastly, in phase III, feasibility assessments were conducted of the barbers.

In phase I, contact and recruitment of the barbers and the barbershops to the study was facilitated through partnering with Community Health Advocacy Partnership (C.H.A.P.), a non-profit, community-based, health prevention, education and advocacy organization. This collaboration was a product of community partnership building efforts of the Tampa Bay Community Cancer Network (TBCCN), one of the 25 NCI-funded Community Networks Program sites, which seeks to implement community-based interventions to impact cancer disparities. Using snowball sampling, we identified four barbershops willing to participate in this pilot project. The main criteria for barbershop inclusion included servicing a predominantly older, African American clientele and the willingness of a pair of barbers at each shop to complete the training and the pilot intervention. The average age of the eight barbers in the project was 50 years old. This research study was approved by the University of South Florida institutional review board, and informed consent was obtained for all research participants.

In phase II, we developed a lay health adviser training curriculum for the barber training classes, which was informed by the principles of Freire's critical pedagogy and Educação Popular (Popular Education) [13, 14] and adapted from an existing curriculum designed for Hispanic lay health workers on cervical cancer [15]. This model of empowerment education encourages learners to take an active role in their community by becoming change agents to improve their own health as well as others in their social network. We evaluated the barber's prostate cancer knowledge gains from the training using a 17-item, previously validated prostate cancer knowledge instrument [16]. The questions were a combination of multiple choice and true/false questions to assess the barber's knowledge of risk factors, prevalence, anatomy, PCS, and informed decision making. The instrument was administered before the training, immediately at post-training, and after the 2-month intervention. In addition, barbers completed written evaluations after the two formal training workshops, and provided feedback during the role-playing exercises in the barbershop. These series of evaluations served as benchmarks for assessing the feasibility of the barber training.

In phase III, we conducted a process evaluation of the pilot intervention and interviewed the barbers at postintervention. We used education encounter notecards to gauge the number of barbershop clients that each barber educated during the 2-month intervention phase (mid-April to mid-June, 2008) and to capture the content of the intervention that was delivered. The barber completed this notecard after each education encounter facilitated at the barber's chair. These data allowed us to assess the everyday practicalities of implementing the barbershop education project, monitor and evaluate the feasibility of the intervention, and gather lessons learned. We also analyzed the barber's postintervention interviews to make future improvements.

Results

Training Curriculum and Workshops

The training curriculum was divided into a series of lessons which covered the role of the barber health adviser, cancer, prostate anatomy, prostate cancer, PCS, prostate cancer treatments, history of popular education and interactive techniques, teaching at the barber's chair, practice sessions, resources and referrals, evaluation, and project objectives. An emphasis on informed decision making was also highlighted. We employed didactic sessions delivered by a urologist, health educator, a community organization leader, and members of the research team, as well as a combination of other adult learning strategies which included group activities and role-playing exercises. The barbers were introduced to the educational materials: (1) a talking points card serving as a quick reference to the curriculum; (2) the project brochure and poster; (3) a plastic prostate model; (4) an educational DVD and mini-DVD player; and (5) a resource list of local and national resources for prostate cancer information and services. The curriculum emphasized the importance of recording education sessions on encounter notecards as one of the evaluation measures for the success of the project (curriculum is available from corresponding author).

The training workshops involved 10 h of training and consisted of an initial “kick-off” evening training, a midday training, and subsequent practice role-play trainings on site in the barbershops. For both the initial training and the mid-day training, the barbers completed post-training evaluations. The barbers were unanimously positive (based on a five-point Likert scale) in their evaluation responses to the two workshop trainings on the overall organization, visual aids, speakers' presentation skills, engagement with the class, answering questions, and meeting their expectations. At the conclusion of the training workshops, we measured the barbers' knowledge using the 17-item prostate cancer knowledge instrument. Barbers scored a pretest average score of 60% (mean 10.12, SD 1.96) and a posttest average score of 79% (mean 13.43, SD 1.39). The posttest scores improved significantly (z=−2.32, P=0.03). In the 2-month follow-up, the second posttest average score was 78% (mean 13.25, SD 1.49), showing no significant difference from the first posttest score, suggesting that the barbers' post-training level of knowledge was retained during the intervention.

Process Evaluation

Barbers were asked to fill out education encounter notecards after each session with a client. The barber collected the following information: date; barbershop location; client age; client zip code; materials used in the education (e.g., brochure, prostate model, poster, talking points card, DVD; topics covered on the talking points card; referrals to community health resources, if made, and the reason; and client's intention to talk with his doctor in the next 6 months about PCS (Table 1). Over a 2-month period, the barbers completed 115 encounter notecards and distributed approximately 500 brochures. The barbers were most likely to use the brochures (74%) in their educational encounters, and the topics most frequently discussed were prostate cancer (84%) and the PSA test (65%). Nine referrals were documented on the notecards to community health agencies for under- and uninsured individuals for health screenings (prostate cancer checks).

Table 1.

Process evaluation data

	2008 (8 weeks)
Training data
Number of barbershops in study	4
Barber Health Advisers (BHA)	8
BHA training sessions	4
Total hours of training	10
Process data from pilot intervention
Brochures distributed	≈500
Number of documented encounters with participants	115
Average number of notecards/shop	28
Average age of participants educated	49
Number of referrals for PCS	9
% no. participants recorded by barber
Use of brochures	74
Use of prostate model	64
Use of poster	57
Use of talking points	57
Use of DVD	20
Intention to discuss PCS with medical provider within next 6 months	77
Discussed prostate cancer	84
Discussed PSA	65
Discussed prostate function	61
Discussed prostate cancer risk factors	57
Discussed cancer in general	40
Discussed informed decision making	31
Discussed local & national cancer information resources	31

Postintervention Barber Interviews

In the postintervention, structured barber interviews, all barbers unanimously agreed that the overall goal of the project was positive and easy to implement, that the education project would help to address the problem of prostate cancer in their community, that it was not difficult to engage clients in participating in the education project, and that project involvement did not interfere with their job as a barber. When asking what other health issues were discussed, the barbers listed cardiovascular disease, colon cancer, diabetes, hypertension, and stroke. All of the barbers felt prostate cancer was an appropriate topic for discussion in their shop.

Discussion and Implications

Our results suggest that: (1) barbershops are appropriate and feasible settings for health promotion; (2) barbers can complete formal training to serve as lay health advisers on prostate health; and (3) barbers are invested in the health of their clients and support the integration of health promotion activities in their shops. Further, the use of easy-to-read brochures, that were readily available and customized for the barbershop setting, were found to help barbers in their interactions with clients.

As the barbershop is a natural social environment, we found that barbers would engage in group discussions and spontaneous educational sessions with other barbers who did not complete the formal training. This finding is similar to that of Navarro et al. [17] who relates that diffusion of information in the community often naturally results from the presence of lay advisers. Consistent with the findings of other studies [7, 18] involving cosmetologists, we found that barbers did not require scripts for the cancer-prevention conversations, but needed to learn the facts in the trainings, so they could weave these facts naturally into their exchanges with clients. Instead of scripts, we used a talking points card to assist the barbers in their educational discussions. The intervention promotion posters, combined with the brochures and prostate model displays, stimulated many conversations around the topic of prostate cancer, and the talking points card provided an organizing context and structure for these discussions.

This feasibility pilot study adds to the small number of studies that suggests that barbershops are feasible sites for health promotion activities, complementing the larger body of research on health promotion projects in beauty shops [6, 19–24]. This study addresses prostate cancer education through the utilization of barbershops, businesses deemed trustworthy by African Americans, while addressing those cultural and experiential factors that may serve as barriers to PCS, such as distrust of medical providers, issues around masculinity, and cancer fatalism, through trained barber health advisers [25, 26]. Our study findings suggest that barbers are willing partners in cancer education outreach activities and will participate in training opportunities to accomplish this task, despite the additional time requirement from training commitments during non-work hours. The barbers were less interested in monetary compensation for involvement in the project than in recognition. Therefore, in addition to granting certificates for completing the training, we provided each barber with a recognition plaque at a capstone dinner event. We are currently exploring ongoing ways of continued engagement with the barbers, such as ensuring that educational materials are stocked in their shops, identifying their interests in other health promotion activities, and furthering interactions with other community partners from TBCCN.

In conclusion, the results of this pilot study suggest the feasibility of the barber training and dissemination approach to improve the health of African American men. Moreover, barbershops represent a promising platform for addressing health disparities and improving community health. This strategy has the potential for replication using the curriculum in other settings, together with the customized health promotion materials.