Openings and Exits in Community HIV Prevention: Exploring Stages of Community-Academic Partnerships

Abstract

Barbershop-based interventions have been increasingly implemented as a means to support culturally-relevant and community-accessible health promotion and disease prevention efforts. Specifically, in neighborhoods of Brooklyn, NY with high HIV seroprevalence rates, barbers have volunteered to support an initiative to help reduce sexual risk behavior. After implementing the Barbershop Talk with Brothers program for five years, we explored how program participation has impacted barbers’ HIV prevention and counseling skills to promote their clients’ health, and assessed their views of next stages of the community academic partnership, once the specific project ended. Through employing rigorous qualitative research methods with personnel at participating barbershops, key results include that although barbers self-identify as community leaders and even as health educators, they want ongoing support in educating customers about other topics like nutrition and physical activity, including upstream social determinants of health, such as housing and employment. They are also concerned regarding how best to support continuity of efforts and maintenance of partnerships between projects. These findings provide insight toward adjourning community-based participatory research projects, which can inform other academic researchers, organizations, and businesses who partner with community members.

Introduction

Barbershop-based interventions have increasingly been implemented to support culturally-relevant and community-accessible health promotion and disease prevention efforts (Browne, 2006; Fraser et al., 2009; Hart & Bowen, 2004; Holt et al., 2009; Linnan, D’Angelo, & Harrington, 2014; Luque, Ross, & Gwede, 2014; Moore et al., 2016). Specifically, in relation to HIV education and prevention, barbers have shown willingness to engage in partnerships with AIDS service organizations, local health departments, and academic institutions to support HIV risk reduction efforts among their customers (Baker et al., 2012; Brawner, Baker, Stewart, & Davis, 2013; Lewis, Shain, Quinn, Turner, & Moore, 2002; Linnan et al., 2014). Input from barbers in this process has included program design, implementation, and evaluation (CokerAppiah et al., 2009; Lewandowski, Holden, Chang, & James, 2011; Sánchez, De La Rosa, & Serna, 2013). Evaluations of programs based on barbershop partnerships have demonstrated improved health outcomes, primarily related to hypertension control (Hess et al., 2007; Victor et al., 2011). However, data on outcomes from barbershop-based trials in public health areas such as HIV are sparse, with most research in this area focused on early stages of intervention planning and formative research regarding the potential for collaboration (Linnan et al., 2014; Luque et al., 2014). The aim of this paper, therefore, is to gain insights on perspectives from barbers who have been extensively involved in HIV community-based interventions on issues important for maintaining and transitioning these types of programs.

Background

Community-engaged interventions, particularly those grounded in Community-Based Participatory Research (CBPR) methods, often rely heavily on community members to serve as lay researchers. In many barbershop-based interventions the barbers serve as members of the research team and integral project partners. Key tenets of CBPR methods underpin the need to build capacity among all research partners and facilitate the empowerment of partners throughout the research process (Israel, Schulz, Parker, & Becker, 1998). Despite increased recognition of the importance of including the voices of all community research partners, at present, there is little research available on the particular experiences of barbers engaged in CBPR. Such information is necessary to ensure equity in the research process, inform planning for new initiatives and to support sustainability efforts for future partnerships.

To address this gap, we proposed to conduct qualitative interviews with barbers who were either currently involved with or who had recently completed participation in the Barbershop Talk with Brothers (BTWB) program. The BTWB program was a five-year CBPR project developed in collaboration with priority population members, barbers, and barbershop owners and managers, and guided by the Brooklyn Health Disparities Center, a community-policy-academic partnership between the Arthur Ashe Institute for Urban Health, the Brooklyn Borough President’s Office, and the State University of New York, Downstate Medical Center. The primary goal of BTWB was to support HIV risk reduction efforts among Black, heterosexual men in neighborhoods of Brooklyn, New York with a disproportionate prevalence of HIV (Wilson et al., 2014). Specifically, Central Brooklyn was identified due to a high seroprevalence of HIV attributed to heterosexual transmission and a high proportions of residents who identify as Black, African American, and/or Afro-Caribbean (Gwadz et al., 2017; Wilson et al., 2014). In the larger BTWB study, the intervention group received a one-session intervention, containing components that utilized a strengths-based perspective to promote community engagement around HIV prevention, reduce community stigma, increase knowledge of HIV/AIDS, and equip participants with skills to initiate conversations with sexual partners about HIV/AIDS risk reduction. In the attention control group, men received prostate cancer prevention education. Overall, the BTWB program partnered with fifty-three barbershops (24 intervention, 29 control) and recruited 860 men (436 intervention, 424 control).

Barbers played an integral role as community researchers in the overall BTWB project. Personnel at barbershops that served as sites for program recruitment were trained in our program, served as sources of recruitment for eligible customers to participate in the program, and were provided health education on risk reduction support messages consistent with the program. Health education training was provided so that barbers would feel comfortable supporting the program, could discuss aspects of the program that would likely arise during and after implementation, and would receive information that could benefit the barber’s own health behaviors.

Guiding our qualitative interviews in this sub-study with barbers was Tuckman’s Stages of Group Development Theory (Tuckman, 1965). Tuckman’s model focuses on how groups, organizations, or collectives develop, face and resolve challenges, and continue to thrive. The “forming-storming-norming-performing” stages of Tuckman’s model are most widely known and adopted (Khodyakov et al., 2009; Koch, 2007; Peek et al., 2016; Stajura et al., 2012). However, Tuckman and Jensen later added a fifth stage, “adjourning,” sometimes referred to as “mourning,” to focus on processes that impact the end of projects and the dissolution of groups (Tuckman & Jensen, 1977). The adjourning stage marks the end of a process. Group members are able to see what they have accomplished and may also experience a sense of loss (Tuckman, 1977). To date, less CBPR work has focused on the “adjourning” phase, which is arguably the most critical to sustaining partnerships and intervention effects in the community. In this qualitative study, we sought to glean barbers’ perspectives on their participation in the BTWB program, as informed by Tuckman’s first four stages, and importantly, to begin collaboratively exploring the fifth stage—adjourning—among community-academic partnerships.

Methods

For this qualitative sub-study, we employed purposeful sampling, a method often used in qualitative research to identify information-rich themes associated with the phenomenon of interest (Palinkas et al., 2015). Based on a purposeful, criterion sample (Palinkas et al., 2015), our goal was to recruit 20–40 barbers, representative of participating BTWB barbershops, to provide their insight on their involvement in the program and to specifically elicit their thoughts on study adjournment. The sample size was selected in order to ensure representation of barbershops serving primarily African-American and Afro-Caribbean shops in Central Brooklyn and participating in the BTWB program. This sample size is reflective of similarly small, but rich and representative samples used in other qualitative studies of social determinants of health and health promotion (Dill & Ozer, 2016; Ruglis, 2011).

The study team, consisting of two BTWB investigators, field staff and project directors, a qualitative research expert, and a public health graduate student, developed and revised an in-depth interview guide of questions designed to ascertain barbers’ experiences with and feedback on the BTWB program. Our interview guide included questions on challenges and opportunities in implementing and institutionalizing the program—grounded in the first four stages of Tuckman’s group development—and on the processes of study adjournment and looking ahead to needs and opportunities for future collaborations—based on Tuckman’s fifth stage. The study team conducted training meetings regarding the qualitative interviewing methodology to ensure that all interviewers conducted the interviews in a uniform manner. After an initial set of interviews were completed, the team met again to discuss barber’s uptake and completion of the interviews, as well as to address encountered barriers. For example, some interviews were conducted in two parts because barbers needed to discontinue the interview to attend to their customers. The interview review meetings with the study team ensured quality control and enhanced reliability by making certain that all interviewers were administering the interviews as per protocol, while allowing some flexibility to accommodate barbers.

Barbers who agreed to participate in the study met with the interviewers. Interviewers included study investigators and a graduate student. The interviewers described the project, addressed questions, and asked potential participants to provide written, informed consent. All study procedures were approved by the Institutional Review Board at SUNY Downstate Medical Center. Interviews with barbers lasted between 30 to 60 minutes. Barbers received a $40 cash incentive upon completion of the interview, to compensate them for their participation. Interviews were audio-taped and transcribed by a professional transcriptionist. To standardize transcription and in recognizing barbers as co-scholars in the research endeavor, verbatim transcripts were created and were not “cleaned” up to remove slang or grammatical errors (McLellan, MacQueen, & Neidig, 2003).

Data analysis was conducted by faculty from the School of Public Health at SUNY Downstate Medical Center. An ethnographic approach to qualitative data analysis was used. The analysts independently read all interview transcripts to develop the first stage of codes and sub-codes by hand. These codes and sub-codes were words or phrases that assigned a summative attribute to the qualitative data (Saldaña, 2015). These codes included those developed a priori from extant theory and prior research, and those emerging from participants’ insights (Dill & Ozer, 2016; Harding, 2010). To enhance inter-rater reliability, the authors met to discuss their individual codes, to remain consistent with their assignment of codes to particular data, and to ultimately come to an agreement about final codes and sub-codes. A codebook was developed based on these codes and sub-codes, and was used for the final round of coding/re-coding of all interview transcripts. The Dedoose web-based analytical program was used to aid in this process. Based on the codes and sub-codes, themes were developed, which were ideas, phrases, and/or concepts that identified or defined the core meaning and tacit processes of groups of codes (Saldaña, 2015). Next, a set of memos were developed (Emerson, Fretz, & Shaw, 2011), which addressed analytic points of the research data and interpretation of those analytic points. The interview excerpts that follow are included to contextually illustrate and are representative of the key thematic points that emerged during analysis of the interview data.

Results

Twenty-two barbers participated in the qualitative interviews. During initial review of interviews with the study team, it was determined that any additional interviews would not add new information, and recruitment ended because theoretical saturation was reached at 22 interviews. Drawing from the systematic coding described above, we provide illustrative excerpts below to emphasize the key themes that emerged from our analyses. First, these excerpts illustrate the perceived personal values of barbers as health advocates. Next, these excerpts highlight the challenges of focusing on a single disease or condition given the myriad of community health issues faced by barbershop customers. Ultimately, these excerpts reveal the importance of sustained and meaningful public health partnerships with barbershops and suggestions for how to attain these sustained partnerships.

“I’m a kind of an ambassador”: Barbers recognizing their roles in health interventions

Participation in the program confirmed the barbers’ assessment that they play an important role in their shops, communities, and in the Barbershop Talk with Brothers program. They shared:

‘Cause you know most of the time clients always share. Sharin’ with you is their personal business, you know. And their, their personal facts. So it is a good idea, as a barber, you know, to teach them.

There’s certain things that I know that I, I can provide for the men, and in the worst case scenario, pointin’ them into the right direction.

Barbers acknowledge that their customers discuss and disclose a myriad of issues to them. As they continue to build trust and camaraderie with their customers, they leverage these moments to share information with them about HIV education and prevention. Barbers repeatedly remarked that they and their customers believe that “knowledge is power.”

In addition to sharing health information, barbers recognized the importance of their role as trained participants and educators in the Barbershop Talk with Brothers program. They shared:

I see my role as a, I feel like I’m a kind of, somewhat of an ambassador for the project. Alright, ‘cause I feel like, like I have a, I feel I have a very important role to play.

I understand my role at this point, and it’s actually…been comforting to know that I am being part of something that there’s a greater good that I haven’t even seen yet. So I’m doin’ my part.

Yes, because you have ability to reach out to somebody that you may be close with, or you know, gain a trustworthy relationship with, and…you know, spread the word on protectin’ yourself.

Barbers saw their role in the Barbershop Talk with Brothers program as part of a greater movement of HIV education, prevention, and intervention.

“Killers in the Black Community”: Marginalized communities contending with multiple epidemics

Barbers in this study were aware of the pervasiveness of the HIV epidemic in their neighborhoods and within African-American and Afro-Caribbean communities. Additionally, they also recognized that in addition to infectious diseases, these same neighborhoods and communities are also managing chronic diseases, like hypertension and diabetes. They felt that their conversations and possibilities for intervention were “broader than HIV” and proposed specific priorities for future collaboration. They shared:

That’s about two or more, you know, killers in the Black community—diabetes and high blood pressure.

Definitely diabetes, definitely high blood pressure, things that are definitely gonna affect my community, which are those issues.

People, you know, things that people would, they kinda clear up the myths that are involved with, you know, everything they speak on: heart disease, high blood pressure, diabetes, STDs. That’s the good thing ‘cause it clears up the myths. People would believe in certain things that are not true, you know what I’m sayin’, regarding these things. And, it gives ‘em a better understandin’ of the truth.

Barbers also recognized that these chronic conditions are linked to personal behaviors, like nutrition and physical activity, but also to social and structural determinants, such as food environments in their communities. Participants shared:

Yeah, that would be diet, uh, teach them like give them the knowledge how, what they should eat, what they should not eat. ‘Cause a lot, ‘cause so far I see, a lotta people they, they’re oversized, and some of them that I spoke to about this, they don’t really know exactly what they should do, what is what…what could happen to them in the future… and I have, and me personally, I did some research online about it, and I have some knowledge about bein’ helpful, bein’ healthy, and…[I’m] in pretty good, good shape, you know.

High blood pressure…Diabetes. ‘Cause we, everybody while they sittin’ here, eat. Whatever’s close, junk or. greasy food and all a that. So. that’s important.

In relation to environments and social and structural determinants of health, barbers recognized that they are working and living in neighborhoods, particularly in Central Brooklyn, that are undergoing rapid gentrification and forced evictions, after contending with decades of redlining, governmental disinvestment, and spatial stigmatization. One barber remarked:

You hear to where they raisin’ the rent and pushin’ people out, that’s pretty much it. But like what you, as I say before, you be, you all doin’ everything that’s right. So, that’s the only problem I have, and the customers have. And I mean they pushin’ us outta Brooklyn.

Barbers and their customers grappled with these housing and neighborhood realities alongside the threats of the aforementioned chronic and infectious diseases.

“So That The Flame Doesn’t Die Out”: Maintaining community-academic partnerships

Barbers appreciated and saw the value of the BTWB program in their own lives, their roles in their shops and communities, and in their customers’ lives. They shared their thoughts on the study adjournment and suggestions for maintaining opportunities for collaboration:

Because, some people even ask me, like, oh them people comin’ back? I’ll be like, yeah, that, they should be here like next week sometime. So they even, they kinda look forward to seein’ ya all also.

I think it’s to constantly stay in contact with us. ‘Cause I, I will be honest, the more you guys stay in touch with me, the more that I communicate that message. You know what I mean? Like I, I love when you guys stay in touch. I love when you guys come out, because it keeps me involved, and the conversation keeps rollin’. So, the more you stay connected to us, even if it’s just a phone call, or passin’ by, or just checkin’ in on us, and saying you know what, spread the word, that’s important. Staying in, in better communication at all times. So that the flame doesn’t die out.

Based on the realities of grant funding cycles and the ebb and flow of community-academic partnerships, participants’ comments raised important considerations about what “comin’ back” and “checkin’ in” could and should encompass during the conclusion of the formal grant or program period. Researchers committed to community-engaged interventions should give consideration towards how best to support the continuity of health promotion and disease prevention efforts and the maintenance of these personal-professional relationships and partnerships. One barber described how several BTWB program participants thought that the program should be replicated in community spaces catering to Black women, particularly in beauty shops. They shared:

How can you all improve it? Um… more female participation…Like you all come talk to the men, but you all don’t really talk to the females.

I don’t know if you, if you guys goin’ to…beauty salon too. ‘Cause not, not only barbers. ‘Cause beauty, beauty salon is, is almost the same as a, as a barber, which is…which is. female, females talk to, they talk to each other too. Not, not always a guy, ‘cause you know, guys…males feel more comfortable to talk about…anything, as women. But, I mean it. it would be good, it would be good if you did go to beauty salon too, and…anywhere that people already communicate would be great.

While there are several research and funding initiatives that prioritize boys and men of color, it is noteworthy that Black male barbers in Central Brooklyn provided us with programmatic insight that women in their communities can also benefit from health promotion and disease prevention education and programs. This is a very critical and easily attainable next step for future interventions.

Discussion

Barbers involved in the BTWB program provided valuable insight into the impact of the program beyond participant outcomes. As HIV awareness and prevention educators, they are reflexive about programmatic benefits and opportunities for improvement in three main ways. We see these three main findings, informed directly by the barbers, as implications for program and policy change related to capacity building, strategic planning, and directions for seeking continued funding. First, barbers often self-identify as community leaders, and came to recognize their roles as health educators in the community through the BTWB program. This is a confirmation that barbers participate in “performing” the BTWB program, in line with the fourth stage in Tuckman’s model. This finding has implications for leveraging community members, such as barbers, to become integral community health promoters. In our qualitative study, the BTWB program’s structure and commitment to barber health education training and ongoing support helped barbers gain self-efficacy as leaders in health advocacy and confirmed their commitment to these types of partnerships. This finding has implications for the sustainability of community-academic partnerships over time, and therefore the “adjourning” stage of Tuckman’s model. This finding has implications for building the capacity of barbers to be effective health communicators, and for recognizing and supporting formalization of their leadership roles. These types of actions are likely to result in the partnership being in a better position to rapidly mobilize and respond to the changing needs of communities contending with multiple and shifting social needs and health priorities.

A second and closely related finding is the barbers’ desire for a broader range of support in educating customers not only about health issues, such as nutrition and physical activity, but also on social determinants of health, such as housing instability, employment, and food insecurity. This also gives us insight related to the “adjourning” stage of Tuckman’s model. The implications of this finding is that equipping barbers with tools, such as referral systems, to address upstream social and structural determinants of health may be a powerful way to embed health education in the community and capitalize on community strengths, beyond the more traditional model focused on a single health outcome per project. In addition, efforts to better address the root causes of health inequities, which are often of higher concern to customers, may help build interpersonal relationships within small business settings, such as barbershops, and bridge organizational relationships that support both the capacity and sustainability of communities to mobilize toward health solutions.

Lastly, barbers raise considerations about the need to continue support for community- based interventions and for the maintenance and expansion of these partnerships. The expressed concern by the barbers over the continuity of such programs raises one of the largest issues faced with CBPR and other forms of community engaged projects. While CBPR was developed to embed health research into communities, a secondary purpose was to reduce distrust of traditional research in historically marginalized populations (Christopher, Watts, McCormick, & Young, 2008). Once the formal program or funding ends, academic institutions must have conversations with their community partners about what winding-down and disengagement should look like, from a standpoint of affirmation and equity (Kazmer, 2010). The realities that “adjourning” might bring up a sense of loss, disappointment, distrust, and/or relief must be recognized and accommodated (Tuckman & Jensen, 1977). We propose that in much the same way that CBPR projects call for involvement of barbers from the beginning of program planning, the process of adjournment should be explicitly planned for long before any specific project nears completion. Projects, relationships, participants, funding, and priorities all ebb and flow over time. Planning for this level of input from community partners can serve as a basis for agreed upon approaches to maintaining relationships, replicating effective programming in other settings (Linnan & Ferguson, 2007; Yeary, Klos, & Linnan, 2012), generating new ideas for sustained financial support of programming, and managing disengagement and re-engagement in future initiatives.

After five years of implementing the BTWB program, the barbers, their shops, and the academic partners have gone through the “forming-storming-norming-performing-adjourning” stages of Tuckman’s model. Through this qualitative study, more insight was garnered regarding the “performing” stage and, importantly, the “adjourning” stage of a community-academic partnerships and health interventions (Tuckman & Jensen, 1977), which will inform next stages of our partnership’s work. Without the inclusion of post-project qualitative interviews with the barbers, valuable insight into the functioning of the BTWB project would not have been possible. This approach acknowledges and integrates the unique skills and expertise of the barbers (Parsai, Castro, Marsiglia, Harthun, & Valdez, 2011). Whetted with this new knowledge, we are better able to collectively craft what adjournment will look like for our partnership. Having field staff, academic faculty, and student researchers with deep ties in the neighborhoods wherein we work makes conversations and planning around adjournment and sustainability more nuanced, accountable, and achievable. While we acknowledge that this analysis might not be generalizable across the universe of community-based partnerships in health, we recommend that projects that prioritize this type of work include planning for the additional time and expense involved in formally building this type of post-implementation evaluation, and tailor it to the needs and expertise of their community partners.

Conclusions

The BTWB project has been successful in terms of identifying key community members, specifically barbers, to support community-academic partnerships based in community settings. We found that barbers are already serving as de facto community leaders and health educators and possess a wealth of existing knowledge of health issues facing community members. In this qualitative study, we found that barbers were instrumental in providing insights to the types of health programs, in addition to HIV prevention, that should be featured in the barbershops. Therefore, we suggest that community members be brought to the table earlier during the project design process to ensure their voice is at the table when project curriculum and content is being developed. Finally, we found that barbers shared similar concerns as academic researchers on the continuity of the project for the community. These concerns may also be addressed through earlier engagement of barbers and providing barbers with resources to use post-project closure. Given that not all barbers or community partners are likely to have similar thoughts on the best ways to adjourn, and given that all CBPR studies have unique characteristics that may impact adjournment, we recommend that future studies should include qualitative interviews with community researchers as part of shared project planning and in order to garner insight into project implementation that extend beyond research outcomes. Finally, future CBPR projects should build on the capacity of barbers as health advocates to continue to educate the community at large beyond the funding cycle and scope of a project.