NCMHD’s Center of Excellence at the University of Pittsburgh: Using Social Norms to Attack Prostate Cancer among African Americans

Haircuts and prostate screening

Every ethnic group has safe zones; community empowered centers where they can gather, share cultural secrets, connect with their ethnicity’s historical narrative and engage in writing new chapters of that story. Researchers at the University of Pittsburgh Medical Center (UPMC), with support of a grant from the National Center on Minority Health and Health Disparities (NCMHD), are aggressively taking advantage of one of these centers for African Americans - barbershops - to attack a scourge among black men, prostate cancer.

“We hoped to use the culture of trust built between barbers and their customers to address many of the sensitive issues surrounding prostate cancer,” said Mario Brown project director at the university’s Center for Minority Health (CMH).

Prostate cancer strikes African American men 66% more frequently than white men, and the death rate is twice as high. Several studies show that, compared to whites, African American men know less about the disease and are less likely to undergo standard diagnostic procedures such as the prostate specific antigen (PSA) blood test and digital rectal examinations (DRE). Moreover, evidence indicates black men have a heightened concern about the side effects of treatment for the disease.

Health education in the community

“So many of my customers were ignorant about prostate cancer and what’s involved in the screening and treatment,” said John Turner owner of Willie T’s Barber Shop, one of the barbershops engaged in the study. “You know sometimes we don’t want to know if we are sick or talk about it. They’ll talk to barbers like me whereas they won’t talk to other people.”

Using trusted community based institutions as vehicles for health education and health promotion interventions is rooted in social network and social support theory. Studies show that culturally relevant health messages that incorporate social norms and values are most effective if respected community members such as barbers and beauticians deliver them. Researchers at the Center for Minority Health wanted to test the relevance of this theory in their work to eliminate health disparities.

Begun in 2005, the initiative, called H.A.I.R. – Health Advocates In Reach - is a unique partnership between 10 African American barber shops and more than 100 health professionals and students from the University of Pittsburgh’s schools of Medicine, Public Health, Nursing, Dentistry and Pharmacy; the American Cancer Society and the Nursing school at Duquesne University.

Innovative Program Strategy

Barbershops were selected from a list of approximately 120, based on similarities of demographic profiles from the 2000 census. Recruitment of the shops began with phone calls to each owner to make appointments for formal introductions and “pitch the idea”. The strategy of “sampling the product” by getting a haircut proved instrumental in establishing relationships.

Dr. Stephen Thomas delivers grant checks

Two CMH staffers were at each site to observe the interactions between shop employees and customers. Using anthropological research methods, they recorded what they saw and heard with an abbreviated “observational protocol” instrument. This information enabled researchers to identify and then employ appropriate social normative behavior in their own interactions with the barbers and their customers. The barbers were then introduced to the world of public health education, disease prevention and medical care. A person from each shop completed a two-day long lay health advocacy-training program in which they learned CPR, use of the AED and how to implement a number of health promotion strategies. They emerged as certified “Life Savers.”

The barbers did their own teaching as well. Since most of the health care professionals who would be working at the shops were not African American, the barbers gave informal mini-seminars on the cultural norms the doctors and nurses would encounter and sensitized them concerning language and dress.

Program Execution

First, all of the barbershops were provided with culturally sensitive public health educational materials. Working in partnership with a local television station, researchers produced two TV public service announcements that used the barbers, stylists and customers to advertise the upcoming health fair. Weeks before the fair and screening began; barbers began distributing post cards and talking to their customers about the need to be concerned about prostate health and addressing some of the sensitivities involved with being tested and dealing with a prostate problem.

John Turner said, “Sometimes it takes three or four haircuts to get a guy to even consider talking about problems around there.”

Tom Boyd, manager of Big Tom’s Full Service Barber Shop added, “I know some of my customers said they wouldn’t feel right doing what you have to do to get a digital rectal examination (DRE). I told them it made me feel strange too, but I wanted to be there for my wife.”

Community Health Fair

The intervention, designed as a festive health fair, is performed twice a year; on Father’s Day in June and “Take a Health Professional to the People Day” in September. Several shops were set up to take blood samples for PSA tests, and one closed off an area in the back to do DRE’s. Throughout the day, prostate cancer survivors hung-out in the shops to share their story, answer questions, reduce anxiety and make it OK for the men to be screened. Some barbers even offered free haircuts as an incentive to be tested.

“By focusing our efforts on a single day, we believe we can help generate a greater understanding of the importance of regular health screenings while at the same time reaching hundreds of people who tend to have the least access to healthcare," explains Stephen B. Thomas, Ph.D., director of CMH and principal investigator of the NCMHD Research Center of Excellence.

Program Results

In all 41 DRE’s have been performed by clinicians from the UPMC Hillman Cancer Center, 92 PSA blood tests, and 224 men took pamphlets with information about the disease. Since many of the men do not have health insurance, UPMC established a $700,000 fund to pay for any follow up care that might be needed. This was an ethical consideration insisted upon by the research team and the health system agreed.

Perhaps more importantly, by establishing the relationship that enabled this screening, a more permanent bond was born. The schools of Nursing and Pharmacy now use this initiative to give their students “field placement and cultural confidence” training by placing them in these sites under the supervision of a professor or proctor.

These shops are located in what is often called drive by neighborhoods; racially segregated, poor, isolated communities that define underserved. Many of the health professionals admit they would have never stopped here or realized how nuanced and vibrant the communities are. The program has become so successful that experts from as far away as the Mayo Clinic in Rochester, MN are participating and learning through a formal credit course titled, Urban Immersion.

"I gained valuable experience and confidence in delivering health services to people in a non-traditional setting," said Dr. Farah Ramirez-Marrero, a physiology researcher from the University of Puerto Rico who is currently a K12 scholar at the Mayo Clinic. "Whether I’m working with minority or underserved rural populations in the Midwest, or with disadvantaged patients in Puerto Rico, it’s important to build trust and really listen to what people want and need in regards to healthcare. Not everyone has the money, transportation or support to come to a large medical center so we need to find ways to take the center to them. Everyone deserves decent healthcare and a chance to participate in medical research that could benefit them or their family."

As an extension of the field placements and health promotion interventions, the University of Pittsburgh’s NCMHD Center of Excellence developed an “Adopt-a-Shop” model to allow CMH to act as a conduit for various schools of health sciences for ongoing community based training. Health professionals worked in barbershops for up to 20 hours a week performing health screenings, education activities and feasibility studies. CMH believes that developing this type of infrastructure is crucial for future successful research activities within the African American and other underserved communities.

“What we are creating here is a health promotion greenhouse,” said Dr. Thomas, “a place to nurture innovation, grow new models, and propagate successes that benefit individual communities and develop new knowledge in the science of eliminating health disparities.”

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