Problem Addressed

• A disproportionate burden nationally and statewide: Nationally, one in nine individuals over age 20 years has chronic kidney disease that, if untreated, usually leads to total kidney failure. African Americans are disproportionately affected by the disease. Nationally, rates of kidney failure and end-stage renal disease are at least four times higher for African Americans than for Whites. African Americans account for 14 percent of Michigan's population, but represent 47 percent of those on dialysis and 45 percent of those on the kidney transplant waiting list.¹
• Diabetes and hypertension the main culprits: Nationally, two-thirds of individuals with undiagnosed and untreated diabetes and hypertension will develop chronic kidney disease.¹ In Michigan in 2004, diabetes and hypertension accounted for more than 70 percent of all cases of kidney failure.²
• Benefits of early education and treatment: Many, if not most, cases of kidney failure caused by diabetes or hypertension can be prevented or delayed. Lifestyle changes to prevent diabetes and hypertension, along with appropriate treatment of these conditions, can save lives.²

Description of the Innovative Activity

• Recruitment of stylists: The program recruits stylists on an ongoing basis through direct mailings to salons and personal contact by the program coordinator and current participants in the project. To assist with this task, the National Kidney Foundation of Michigan purchased Michigan's list of licensed cosmetologists. The mailings contain dates and addresses of the training sites, along with a telephone number to call should a stylist wish to attend a training session. The training sessions also can accommodate stylists who attend the training without signing up in advance.
• Training: Stylists interested in being lay health advisers attend a 6-hour workshop in which they learn to motivate their clients to make lifestyle changes that can prevent kidney disease, diabetes, and hypertension and to seek medical advice. The training also includes instruction on nutrition and exercise. As an incentive, stylists receive a $50 stipend for attending the workshop. They are also offered the opportunity to develop additional leadership skills by joining an advisory group for local program issues and logistics, participating in public speaking, and serving as a media contact. Some stylists also become program trainers.
• Implementation at the salon site: After training is complete, the stylists return to their salons, where they initiate "health chats" (conversations about healthy living) with their clients. Stylists have flexibility as to when they initiate a health chat, although most occur when the client is in the salon chair. The stylists begin the conversation by talking about how they recently attended a National Kidney Foundation of Michigan–sponsored training session on diabetes and high blood pressure, and then they share the information they learned. They also hand the client a brochure entitled Are You at Risk for Diabetes and High Blood Pressure?, which contains educational material as well as a symptoms checklist. Chats take on average between 10 and 15 minutes, including time to fill out the symptoms checklist in the educational brochure. Stylists attempt to engage each client in two health chats, as described below:
  • First chat: This conversation focuses on better nutrition, physical activity, medication compliance, or smoking cessation. Stylists urge clients to discuss their risks with a doctor and get tested. At the end of the first health chat, clients complete a self-administered "chat form" that asks about their intentions regarding disease prevention and seeking the advice of a physician.
  • Second chat: This conversation takes place at least 30 days after the first, which gives the client enough time to visit a doctor or make lifestyle changes. After this discussion, clients report their successes to date on the second part of the chat form, which serves as the primary tool for evaluating program outcomes. The stylist collects the completed forms and gives them to the program coordinator, who returns them to the National Kidney Foundation of Michigan for entry into a database used for analysis.
• Client and stylist incentives: In addition to the $50 paid for training, stylists receive $4 for each completed chat form. In the program's initial years, clients received a healthy soul-food cookbook at their first visit and a canvas bag containing beauty and other products after completing the second chat. Owing to a lack of funding, the program no longer provides client incentives.
• Followup with high- and moderate-risk individuals: Program staff use the chat forms to identify high- and moderate-risk individuals. At the program's inception, certified diabetes educators called high-risk clients to encourage them to see a doctor and to reinforce healthy behaviors. Owing to a lack of funding, however, these educators are no longer available to conduct this outreach. The program currently conducts followup with clients by regular mail. High-risk clients receive a letter that strongly recommends they contact their health care provider as soon as possible to be screened for diabetes; moderate-risk clients receive a similar letter, but with a less urgent recommendation to discuss their diabetes risk factors at their next doctor's visit. Both letters include information on ways to reduce diabetes risks and are accompanied by risk-appropriate educational literature.
• Referrals to other National Kidney Foundation of Michigan and partners' programs: Information provided in December 2012 indicates that stylists make referrals to other National Kidney Foundation of Michigan and partners' programs in the community. The National Kidney Foundation of Michigan offers free and low-cost evidence-based low-impact fitness classes, a chronic disease self-management program, and the National Diabetes Prevention Program. Healthy Hair will now be used as a way to actively recruit for those programs and a conduit for spreading information about available resources. All programs have a tracking form that allows participants to indicate where they heard about the program. This renewed emphasis on cross-recruitment will help ensure that the National Kidney Foundation of Michigan's programs reach the most at-risk population in a meaningful way.

References/Related Articles

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Innovator Disclosures

Results

• Increase in preventive behaviors: Sixty-three percent of 21,046 clients took at least one step to prevent diabetes, high blood pressure, or kidney disease, including seeking medical advice.¹ Information provided in December 2011 indicates that in 2010, 74 percent of clients made at least one healthy lifestyle change; such changes included increasing daily consumption of fruits, vegetables, whole grain foods, or low-fat or fat-free dairy products each day; limiting salt intake; choosing foods low in fat; increasing physical activity; and stopping smoking.
• Improved diet: Clients who made dietary improvements reported that they increased their fruit (27 percent) and vegetable (23 percent) consumption, began choosing foods low in fat (47 percent), or limited their salt intake (57 percent).¹
• Increased exercise: Thirty-eight percent of clients reported that they increased their exercise.¹ 
• More consultations with doctors: Of those clients who saw their doctor between the first and second chat (4,964), approximately 80 percent (3,965) reported talking with their doctor about their risk for diabetes, hypertension, and kidney disease. Approximately 2,319 clients were tested for at least one of these conditions, and 782 were diagnosed with one or more of these diseases.¹ Information provided in December 2011 indicates that in 2010, 52 percent of clients visited their physician or made an appointment to visit their physician.
• Continued behavior change shown in additional followup: Project staff attempted to contact 200 participants in two cities (Flint and Grand Rapids) who agreed to additional contact from the National Kidney Foundation of Michigan. The 60 participants successfully contacted were surveyed 6 months after participating in the campaign, and these surveys showed continued behavior change:
  • Approximately 60 percent reported exercising at least 3 to 4 days a week.
  • Eighteen percent reported eating at least five fruits and vegetables a day.
  • Seventy-five percent referred to an enduring campaign message that reflected improved knowledge and skills or reinforcement of healthy behaviors.¹

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Securing initial funding and support: The National Kidney Foundation of Michigan received initial funding from a local partner to start the program. The Veterans Administration Center for Practice Management and Outcomes Research, which works to identify and evaluate innovative strategies that lead to accessible, high-quality, cost-effective care, agreed to provide pro bono consulting services to assist with project development. The Michigan Department of Community Health also provided staffing support and public health expertise to assist with the program's development.
• Developing the program materials and curriculum: Working with the outside consultants, project staff created the health chat forms and other materials, including outcomes tracking systems. National Kidney Foundation of Michigan staff members developed the curriculum to train the hair stylists in collaboration with a statewide advisory committee representing medicine, public health, nutrition, social work, and education. In some cases, local program coordinators customized the materials to meet local needs.
• Training: The National Kidney Foundation of Michigan recruited experts to teach the 6-hour training course, including members of professional volunteer committees such as the Community Advisory Committee and Scientific Advisory Board, which includes public health professionals, physicians, nurses, dietitians, and social workers.
• Expanding to additional cities: The project initially trained stylists in Detroit, Grand Rapids, and Southfield. In 2001, the National Kidney Foundation of Michigan expanded the program to Flint, Lansing, Muskegon, Pontiac, and Saginaw. In 2006, the program was introduced in Ypsilanti.

Resources Used and Skills Needed

• Staffing: Each city's program is staffed by a program coordinator, most of whom have a bachelor's degree and are from the community that is being served. Some coordinators have been stylists in the past. As noted, the program initially used certified diabetes educators to provide followup for high-risk program participants. A full-time data analyst is responsible for analyzing all of the data received from local program sites.
• Costs: The estimated total direct and indirect costs of the program are approximately $45 per client served. Key program expenses consist of direct mailings (which cost between $3,000 and $5,000 per city) and training, including the $50 payment to each stylist who attends the workshop, roughly $3 to $5 to cover the cost of a binder for each person trained, and $300 in food. Program coordinators and the data analyst are paid staff and also add to the cost of the program. Program trainers volunteer their time.

Funding Sources

Getting Started with This Innovation

• Search broadly for funding and support: Seek funding and in-kind support from local partners in the community, including voluntary health agencies, hospitals, primary care centers, public health departments, and civic and church groups. These organizations can provide support for training (staff and space), program staff (e.g., program managers, diabetes educators, data analysts), educational brochures, cookbooks and other incentives, marketing aids, and even blood pressure checks in salons.
• Utilize the advice of constituents: Seek input from key constituents on program development, including the curriculum, training, and materials.
• Hire staff from within the community: Recruit program coordinators who have ties to the community or who otherwise have the ability to connect to the community.
• Tailor the program to those it serves: Customize program materials, training materials, and data collection forms to the target population.

Sustaining This Innovation

• Identify sustainable funding: Seek sources of ongoing funding for staffing, program materials, and incentives, such as the USDA matching fund initiative.
• Provide ongoing support for stylists: Continuously support the hair stylists to maintain the quality of their interactions with clients. Program staff have used midprogram lunches with stylists to sustain their commitment and enthusiasm, and to address problem areas.
• Continuously recruit new participants: Stress personal outreach and multidimensional marketing (including direct mailings, peer-to-peer recruitment, and media "blitzes") to recruit additional stylists to the program.

Additional Considerations and Lessons

• The National Kidney Foundation of Michigan's Dodge the Punch: Live Right™ African-American men's health program was developed as the male counterpart to the Healthy Hair Starts with a Healthy Body™ program. Information provided in December 2012 indicates that since the spring 2005 pilot campaign, more than 350 barbers in Detroit, Grand Rapids, Muskegon, and Flint have been trained to become lay health educators in their barbershops. These barbers have successfully implemented 25 campaigns, reaching more than 7,500 African-American barbershop clients with important health messages and educational materials in an effort to reduce the high rates of chronic kidney disease, diabetes, and high blood pressure in their communities. Clients are urged to make healthier food choices, get 30 minutes of exercise on most days, stop smoking, and take prescribed medication properly if already diagnosed with diabetes or high blood pressure. They also are encouraged to see their doctor to discuss their disease risks and get tested for disease.