David Lee, MD, of NYU School of Medicine, discusses barbershop initiatives and how they can impact the health care of a community as a whole.
Health disparities among patients of a different race or ethnic background are one of the most glaring and persistent issues in healthcare—regardless of field or specialty.
The issues become even more obvious when examining certain conditions—particularly cardiovascular disease and diabetes among racial or ethnic minority groups, which makes community-based preventative care initiatives a popular talking point among physicians practicing in or near underserved communities.
Barbershop initiatives have become increasingly popular in recent years as a means to bridge the gap in preventative care and build trust between physicians and individuals in underserved communities. A recent study, published in JAMA, examined use of such a program to help identify diabetes in at a group of barbershops in Brooklyn, NY.
In the study, investigators conducted HbA1c testing in a cohort of more than 250 African American men and identified close to 100 individuals at risk of diabetes based on their HbA1c levels. While the results indicate the effectiveness of this approach, it also raises questions about the health care system as a whole and what current problems add to these ever-present issues.
For more on how barbershop initiatives and other similar programs can impact community health and spark a larger conversation regarding the health care system as a whole, HCPLive® invited the lead investigator for that study to take part in an edition of the DocTalk Podcast.
HCPLive: Hello and welcome to the DocTalk Podcast.
I’m Pat Campbell—editor with HCP Live and I will be your host for this edition of DocTalk.
In today’s episode, you’ll hear a phone conversation I had with Dr. David Lee, MD, MS, assistant professor and director of the Health Geographics Research initiative at the NYU School of Medicine.
Dr. Lee is the lead author of a recently published research letter in the Journal of the American Medical Association, that examined the results of a recent study he led examining the use of barbershop initiatives to identify disease and improve health in underserved communities.
In this study, Lee and a team of colleagues from the NYU Grossman School of Medicine and Touro College of Osteopathic Medicine conducted HbA1c testing in 8 barbershops in Brooklyn. In short, the initiative successfully tested 290 African American men and found 26 had an HbA1c at a level of 6.5% or higher and 82 had a level between 5.7% and 6.4%, which is the criterion for diagnosing prediabetes. So identifying nearly 100 people at risk of or who already had diabetes over the course of their study.
While the results demonstrate the ability of these initiatives to reach underserved groups, barbershop initiatives like that in Lee’s study or those seen in other well-known studies naturally create questions surrounding our health system as a whole and whether these programs are feasible for real-world application or just clinical research.
So, without further ado here is my conversation on that very topic with Dr. Lee. Enjoy.
Lee: Okay, great. So my name is David Lee. I'm an ER physician and an assistant professor at the NYU School of Medicine. And my research interests are really in studying the geographic burden of disease and identifying communities that have a higher risk of disease and trying to find ways that we might try to reduce that risk or improve the treatment of disease in those communities.
HCPLive: Alright, thank you for that. And now, just before we begin, Dr. Lee was involved in a study—he was actually the lead author of a recent study published in JAMA that explored barbershop initiatives to test for HbA1c in African American patients. Now I'm sure you could explain it a little bit better than I could. But why don't you take our listeners through some of the methods and then the results of your recent study?
Lee: Absolutely. So, ultimately, what we did was we identified some communities using some data that we had previously analyzed in another study that looked at estimating the problems of diabetes in New York City. We could do this with a high geographic specificity and could identify the exact neighborhoods where diabetes was much more prevalent. So, then what we did was, we have a network of barbershops through my collaborators here at NYU that we've worked with before and we identified several barbershops in these communities who are willing to participate in this study.
So, the study basically went in and approached men who are customers at barbershops waiting for a haircut. These are black-owned barbershops and their clientele were predominantly black and African American. We had research corners that go up ask if these men would be willing to participate in having a hemoglobin a1c done by point of care, which is just a quick finger prick. Then, we used a point of care hemoglobin testing device, which allowed use to give results in five minutes and then we tested men who didn't have a history of diabetes. We found that among these men that didn’t have a history of diabetes, unfortunately, almost 9% of them had point of care hemoglobin a1c that would suggest a diabetes rank and then many of them and also demonstrated evidence of prediabetes based on the test result. So, that's what we had written up them talked about in the study.
HCPLive: Right. Now, can you elaborate more from your perspective on how these types of initiatives even on a smaller scale, like yours which included just eight barber shops—how can these initiatives have a broader impact on community health through education and awareness?
Lee: Well, I think based on the evidence that's out there, somebody who's detected with diabetes through screening compared to the person who essentially waits for the development of symptoms and is clinically detected to have diabetes after the symptoms have arrived—we know the people who are screen-detected cases have half the mortality rate of somebody who waits to find out they have diabetes based on symptoms. With diabetes, obviously, there's potentially a long delay that can occur because the symptoms are not that obvious.
People can have diabetes for a long time before they develop the thirst or frequent urination or even the numbness and tingling in their extremities and I think, unfortunately, that happens a lot more frequently in the black in African American communities. So, I think screening programs like this can try to catch people earlier and I think, even among the few men that we screened and identified, when we talked with them it was quite a wakeup call for them. I would say that the receptivity towards doing these screening programs for diabetes in these communities were largely because not only did we have a good relationship with the barbers and the barbershops, and they trusted their barbers as a setting where they felt comfortable but in addition, a lot of these men reported that they had family members or loved ones who had either suffered serious complications from diabetes, being on dialysis, losing a lower extremity, or had died from diabetes at an early age.
So, I think with so many of these men having witnessed these sort of effects of diabetes firsthand, I think a lot of them, at least initially, were shocked to find out that they were diabetic, in the diabetes range, or had pre-diabetes, but then I think ultimately, probably motivated a good number of them to make some changes.
HCPLive: Now your study isn't the first that we've seen to examine barbershop initiatives. I know there was a study that is a pretty notable that examined a similar thing, but high blood pressure in barbershops in Los Angeles County. Outside of HbA1c and the other studies that we've seen examining high blood pressure at barbershops—are there any other conditions that you think this sort of lends itself to as an applicable way and a more practical way of screening for disease?
Lee: So my colleague, Joseph Ravenell, who's one of my mentors and one of the key faculty members at NYU, has been studying the use of barbershops in these communities for a long time. His studies have not only looked at hypertension, but he's also done colorectal cancer screening, which I think is the second leading cause of cancer deaths, and then there's also individuals at NYU, who are studying community-based approaches to doing prostate screening for prostate cancer.
So, there are definitely other venues for studying this and even my close colleague in the emergency department Steve Wall has used this approach to try to understand the patterns of organ donation among the black and African American communities and other minority groups—especially since we know there's such a need for more organ donation in these communities. So, there's just been a lot of studies that have sort of leveraged the barbershop settings and hair salons and just other community-based settings to do this work.
HCPLive: Now, the big question about these barbershop initiatives—they're incredibly interesting to read as studies and for clinical research and things like that—but do you think that these type of initiatives could be feasible if implemented on a larger scale? Is the amount of diagnoses worth the amount of energy and dollars that would have to be spent to implement something like this large scale?
Lee: Yeah, I mean, those are really good questions and I'm not sure that those are questions that are study really answers. I mean, the tough part about, clinical research is that sometimes results don't necessarily translate to just the real-world setting, because in a clinical research study, you have funding to pay for research coordinator to be there identifying customers in the shop and we haven't necessarily plowed through any sort of cost-effectiveness or sort of analysis of whether that would be scalable in a large scale.
Obviously, there were those studies that talked about having a pharmacist work with barbershops and there are all sorts of interventions that show that the barbershop can be effective, but then the question is just the broader, like scaling up of these initiatives. Can you do that at scale?
I think some of those questions are yet to be answered. Then, I think some of the also important questions that need to be answered before thinking about going to scale with any of these initiatives is that what's the next step? So, you can identify people who have diabetes and pre-diabetes, but is screening enough?
It probably isn't for many people. I mean, some people might end up changing their health behaviors radically—and we've definitely seen that in some of our follow up cases of the patients who are identified with diabetes and pre-diabetes study—but then, for the vast majority, it's more possible that they're not able to either make sustainable change or make any changes at all. So, the question is "What you do for them?". And is there an effective way of basically either delivering care in the barbershop setting or transitioning them to care outside the barbershop setting or is there some sort of medium where we can get the people who we identify the treatment that they need?
I think it's kind of obvious that our current health care system whether directly or indirectly discourages people of lower socioeconomic status from seeking medical attention sometimes.
HCPLive: Do you think that there would still be a place for these outreach centered initiatives, even if that weren't the case? Because I know you see in a lot of communities, a lot of times people don't seek out help from their cardiologists until after they've had their first event. Do you think that there would be a place for initiatives like this even in communities that aren't largely African American?
Lee: Yeah, I mean, I think the disparities themselves are crushing in many ways and they definitely exacerbate a lot of these issues of access and preventive screening and those sorts of measures that people need. Ultimately, the way the healthcare system is set up, I think that often it is a little bit reactive. That might be also just because, by nature, people are a bit reactive.
If I wasn't a doctor myself and required to go for annual checkups, I kind of wonder myself how often I would be going to the doctor on a regular basis if that wasn't like part of what I had to do for my work. So, part of the process for us—we end up going to the doctor when you feel sick and if it's something that's creeping up on us like diabetes, we might not necessarily go to the doctor and find out that we have these conditions.
So I definitely think there is evidence that preventive screening measures, even though it's recommended by clinical guidelines—whether it's the US Preventive Task Force or just the clinical guidelines developed by medical associations—the percent of people who live up to those guidelines, is probably lower than we're hoping for. So, there's got to be a way that we try to approach and improve that. Whether it's in a community that is suffering deep health disparities, which they probably even need it much more so, or a community that's generally doing well off, I think everybody could use more preventive services. Especially the ones that I really recommended.
HCPLive: Okay, now Lastly, before I let you go, um, this last question is a bit of conjecture. Obviously, in some communities, there's a bit of distrust maybe with public health or, again, people don't really see the need to go to the doctor for preventative care.
Did you see a change in community members at all, near or around any of these barbershops? Specifically in those that weren't diagnosed with diabetes as a result of your tests?
Lee: I don't know that we necessarily tracked that among the people who weren't diagnosed with diabetes or pre-diabetes. We have been talking to the ones that had been diagnosed with diabetes and pre-diabetes about their health and how they've either made changes or not made changes. But I think the issue that you touch on in terms of the distrust and issues around that with the healthcare system are serious. I would frankly think they're not very well understood in our medical community.
I think, unfortunately, there are many times when whether through training or just the rigors of residency and the process of becoming a doctor, there's just develops this—I don't know if I would call it antagonism—but just like, difference of opinion between patients and doctors, or sometimes I see, you know, people who are in training, they almost get into this position where their first reaction is to not trust what the patient says or if a patient comes to them and says, "Hey, Doc, I need a, you know, CAT scan or an MRI," sort of the first thing that comes back to the doctors mind is "No, you don't need that," and there's not like a "Let's sit here and hash this out what you need and what you don't need".
Ultimately, I think hearing from the men in these communities and their experience with the healthcare system it's very telling to me. We're trying to aggregate these thoughts that they've put together into a publication and a study that we're hoping to disseminate soon, but I think we need to take a step back and listen to patients and people a lot better and I think what I'm hearing from a lot of the men that are diagnosed with diabetes and pre-diabetes in these communities, is that starting a medication to them feels Like—in terms of one of the participants said—that feels like the game's over and that they're stuck on a medication for a lifetime.
So, trying to understand what that might mean, I think it would be too easy to for a doctor to say, "Oh, that patients not compliant or they're not adherent, they're not gonna stick with the regiment that we've given them". To really understand where the patients coming from and why they feel that way and what can you do, are there any sort of treatment options that we can develop that will help this person in the context of how they think about their health and how they think about healthcare, I think that's really critical to basically coming to a good therapeutic relationship with the patient.
I think without doing that, we're going to see a lot of these health disparities continue and a lot of people are going to mistrust the healthcare system. Yeah, they're going to continue to mistrust the healthcare system, because they don't feel like their voice is being heard and so then they don't really follow along with what's being recommended because there isn't trust in the therapeutic relationship.
HCPLive: Alright, thank you for that insight. Now, just before I let you go, is there anything else you wanted to touch on that I might not have asked you about?
Lee: No, I don't think so. I just really want to encourage the people out there who are doing this community-based research. I just talked to a fellow at Stanford who's doing this work, and he's working on hypertension and barbershops. His name is Dr. Kenji Taylor and just hearing stories that are very inspiring to me, because it shows me that there are good people doing this good work. I think we need more of it that way. our health care system sort of can expand its thinking beyond the four walls of the clinic and think about the communities that are really affected by these sometimes devastating health issues.
HCPLive: Yeah, I definitely agree. There's a lot to look into when it comes to these barbershops and larger-scale community health initiatives and issues that currently exists in our healthcare system, but I just wanted to say thank you, Dr. Lee, for taking part in the DocTalk Podcast. We appreciate you being here today.
Lee: Okay, thank you so much.
HCPLive: That’s it for this episode of the DocTalk podcast. Please make sure to check out HCPLive on Twitter, Facebook, and LinkedIn. I’m Pat Campbell with HCPLive. Thanks for listening.