parT II: OriGiNal PapEr

Hair Salon Stylists as Breast Cancer Prevention Lay Health Advisors for African American and Afro-Caribbean Women
Tracey E. Wilson, PhD Marilyn Fraser-White, MD Joseph Feldman, DrPH Peter Homel, PhD Stacey Wright, MPH Gwendolyn King Beverly Coll Sonia Banks, PhD Donna Davis-King, PhD Marlene Price, MD Ruth Browne, ScD
Abstract: Objectives. To assess the effectiveness of breast health promoting messages administered by salon stylists to clients in the salon setting. Methods. Forty salons in an urban, minority area were randomly assigned to provide messages to clients or to serve as controls. Pre-intervention surveys were completed by 1,185 salon clients. Following program initiation, assessments of 1,210 clients were conducted. Results. Among women completing surveys at control salons, 10% reported exposure to breast health messages, as opposed to 37% at experimental salons (OR 5.4, 95% CI 3.77.9). Self-reported exposure to stylist-delivered messages was associated with improved breast self-examination rates (OR 1.6, 95% CI 1.22.1) and with greater intentions to have a clinical breast examination (OR 1.9, 95% CI 1.13.3). Conclusion. Hair salons are a potentially important venue for promotion of health behaviors related to breast cancer detection. Key words: Health education, women, breast self-examination, minority groups, communitybased participatory research.

TRACEY WILSON is Associate Professor in the Department of Preventive Medicine and Community Health at the State University of New York (SUNY), Downstate Medical Center, in Brooklyn, NY. GwENDOLYN KINg, BEVERLY COLL, DONNA DAVIS-KINg, are all affiliated with the Arthur Ashe Institute for Urban Health in Brooklyn. JOSEPH FELDMAN, MARLENE PRICE and, are all affiliated with the SUNY Downstate Medical Center. MARILYN FRASER-WHItE and RUtH BROwNE are affiliated with both the Arthur Ashe Institute for Urban Health and the SUNY Downstate Medical Center. PEtER HOMEL is affiliated with the Beth Israel Medical Center in Manhattan, StACEY WRIgHt with the New York City Department of Health and Mental Hygiene, and SONIA BANkS with Virginia Commonwealth University. For information on the program, contact the Principal Investigator, Dr. Ruth Browne at the Arthur Ashe Institute for Urban Health, (718) 222-5953. Journal of Health Care for the Poor and Underserved 19 (2008): 216226.

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lthough breast cancer incidence is lower for African American women in the United States than for White women,1 the age-standardized death rate for breast cancer is significantly higher.2,3 It has been posited that these differences are related to a number of factors, including lower likelihood of African American women receiving breast conserving surgery,4 greater risk for obesity,5 more aggressive breast carcinoma tumors,6 higher reproductive risk factors,7,8 and the presence of co-morbid conditions such as diabetes and hypertension.9 It is clear, however, that disparities in timing of diagnosis are also a major contributor. Adherence to mammography, clinical breast examination, and breast self-examination among African American women falls below American Cancer Society recommendations.10 African American women are typically first diagnosed with cancer at a later stage than White women are, a phenomenon that may be due in part to lower utilization of screening methods, such as regular mammography, and inadequate follow-up rates related to abnormal findings from screening tests.1114 Despite widespread awareness of the need to promote breast cancer screening behaviors in communities of color, there are few programs that are culturally appropriate, acceptable, effective, and accessible to those in greatest need of services.15,16 The use of lay health advisors to promote behavior change represents one promising approach to meeting this need, and has been shown to be useful in promoting breast cancer screening practices.17,18 For the purpose of reaching African American and AfroCaribbean women, the beauty salon affords a promising setting for health promotion efforts and for recruiting lay health advisors. Beauty professionals in these communities enjoy a level of trust from their clients that opens up avenues for communication that may not always be available to researchers from outside the community.19,20 In addition, many women within the African American community regularly visit hair salons, presenting an opportunity for widespread and regular dissemination of health messages to this population.21 For instance, the North Carolina BEAUTY and Health Project demonstrated both that salon stylists often engage naturally in health-related discussions, and documented the willingness of employees at salons to deliver health messages to customers.22,23 In preliminary studies of clients at hair salons in our service area, we found that women had a need for improved knowledge regarding breast cancer.24 The Soul Sense of Beauty program was implemented to assess the effectiveness of hair salon stylists as lay health advisors in promoting the breast health of American and Caribbean women of African descent in geographically defined, low-income areas of Brooklyn, New York. The goal of the program was to promote customer screening practices by fostering the ability and motivation of stylists to deliver theoretically-based and culturally appropriate breast health messages.

Methods
Respondents. Clients receiving services at experimental and control salons were eligible to participate in program evaluation activities. Randomization procedure. We targeted several neighborhoods (East Flatbush, Flatbush, Crown Heights, Bedford-Stuyvesant, and East New York) in Brooklyn, New York,

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as a focus for program activities. Predominantly, residents of these neighborhoods are minority group members (African American, Afro-Caribbean, and Hispanic) and are more likely to live below the poverty line than are residents of New York City overall.2527 A list of all salons providing services in our target neighborhoods was compiled through phone book and Internet searches as a function of ZIP code. We randomly selected 40 salons (28 for intervention activities, 12 for no-treatment control sites) from the target neighborhoods using a random number generator. We contacted the proprietor of each selected salon to assess willingness to participate as either an experimental or control salon site. Although we calculated that implementing intervention activities in a smaller number of salons would have yielded a sample size sufficient to conduct our analyses, we chose to recruit a larger number of these salons in order to assess the feasibility of implementing salon-based interventions on a community-wide basis. Randomization was conducted after proprietor agreement to take part in the study. When a salon proprietor refused to participate, we randomly selected the next salon from that neighborhood. In total, we approached 257 salons in order to reach our goal of 40 salons. These salons serve a large number of clients. Based on estimates of client numbers reported at participating salons and on logs of customer census taken periodically by study staff at these salons, we estimate that on average, over a 3-month period, each salon provided services to 200 clients. Intervention development and implementation. Partners for intervention development and evaluation included the Director and members of the Arthur Ashe Institute for Urban Health, faculty at the State University of New York Downstate Medical Center, and members of the community advisory group for this program, the Health and Beauty Council. The Health and Beauty Council consists of local community health leaders, including salon owners, breast cancer survivors and other health care advocates, board members and leaders of local media outlets and foundations, and academic partners. This program built on several years of community-based health promotion and research led by the Arthur Ashe Institute for Urban Health in partnership with local organizations, academic centers, and businesses in Brooklyn. These partners worked together on defining the approach to programming and evaluation, the content and wording of training sessions and evaluation instruments, methods for data collection and survey content, monitoring of progress toward program goals, and interpretation of results. Salons were excluded from program activities if the owner was a member of the Health and Beauty Council. The training curriculum for salon stylists was developed by program partners and designed to promote both skills and motivation to provide correct and consistent breast health information to female clients on an ongoing basis. Stylists were trained to conduct tailored and culturally sensitive counseling that would encourage clients to engage in breast health behaviors. Breast health recommendations at the time of study start-up included monthly breast self-exams, annual clinical breast exams, and routine mammography for women 40 years of age and older. Both the content of the training and the messages to be administered to clients by stylists were informed by Social Cognitive Theory.28,29 The training was designed to promote skills and self-efficacy for conducting counseling with clients. Components of this interactive training targeted (1) improved communications skills related to breast health through role-playing and

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modeling of interactions, (2) sensitization to cultural and practical issues involved in interactions with customers, (3) improvement in knowledge and the ability to explain issues involved in the etiology, prevention, detection, and treatment of breast cancer, and (4) skills-building related to tailoring messages to clients based on their receptiveness to discussing and engaging in breast health behaviors. Stylists were instructed in how best to promote client skills and self-efficacy for engaging in breast health behaviors and motivation to engage in breast health behaviors. Training for each stylist involved two, two-hour workshops, a reference handbook related to key information provided in the training, and ongoing support and technical assistance for stylists and salon staff by staff at the Arthur Ashe Institute for Urban Health. Each stylist was provided with contact information for program staff so that any questions could be answered as needed. Program staff made frequent visits to salons to support stylists in their promotion of message delivery throughout the time during which the program was administered. Salon stylists also were given written materials to provide to clients on where to receive services for breast cancer detection and treatment. Stylists were compensated for their participation in the training with professional development classes by a renowned hair stylist. The hair stylist donating these classes was a member of the Health and Beauty Council. These classes were valued at approximately $800.00. In addition, stylists were provided $30 cash to cover time and expense in traveling to the site of trainings. Stylist training was implemented in waves, based on planned initiation of intervention activities in that salon. Implementation of the program at experimental salons began in January 2002, ended in April 2004, and lasted for three months at each salon. Data collection and measures. Stylist training. Stylists completed a brief, staffadministered assessment both before and immediately following the stylist training. Variables assessed at baseline included demographic characteristics and willingness to provide breast health promotion with clients. At follow-up, we assessed perceived preparedness to discuss breast health, perceived preparedness to provide health education regarding breast cancer detection methods, and willingness to promote breast health screening with clients. Client assessment. In order to assess characteristics of participants at experimental and control salons, we analyzed two cross-sectional assessments of women. The first occurred prior to onset of program activities at the salons. A second anonymous assessment occurred after 1 to 3 months initiation of program services, given preliminary information that salon clients receive services at least on a monthly basis. Participants were not compensated for completion of surveys. Originally, we had implemented a third component of the evaluation, which included a linked telephone follow-up for women who completed the baseline assessment (women who agreed at baseline to be contacted for a follow-up interview were included in the baseline analysis). However, given that the retention rate for this follow-up telephone interview was only 20%, these linked data were not analyzed further. The baseline survey included questions on sociodemographic characteristics, lifetime behaviors and behaviors in the past 3 months related to breast self-examination (BSE), clinical breast examination (CBE), and mammograms; family history of breast cancer; and knowledge related to breast cancer screening and breast cancer. Family history of

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breast cancer was assessed in terms of whether the salon clients mother, a daughter, or a sister had ever been diagnosed with breast cancer. We also assessed breast cancer knowledge through an 18-item scale previously shown to be predictive of breast cancer screening behaviors.30 Each item was scored as correct or incorrect on the scale, and a total score was assigned based on the percentage of items that were correctly answered. Chronbachs alpha for this scale within our population was .78, indicating adequate reliability. The follow-up anonymous evaluation consisted of a 7-question self-report instrument provided to customers by program staff at the time of payment for salon services. Women were asked whether they had conducted a monthly BSE for the last 3 months, if they had had a CBE in the last 3 months, whether they intended to have a CBE in the next 12 months, whether they had received a mammogram in the last 3 months, and whether they intended to have a mammogram in the next 12 months. We did not ask women about actual appointments for CBE or mammography, but instead focused on behavioral intentions to receive these services, as our planning group was concerned that asking for such information might compromise a clients sense of anonymity. The last questions on the survey asked the womans age and if she had received information on breast health from her stylist during the last 3 months. Clients were asked to complete the card and submit it to a drop box. Data analysis. To assess program outcomes in the follow-up survey, we examined the impact of participation in experimental versus control salons. However, we also compared outcomes based on whether or not women reported being exposed to breast health messages, regardless of attendance at either an experimental or control salon. The effect of the study intervention on the measures of breast health behavior was examined using general estimating equations logistic regression models (GEE), an approach that adjusted for any clustering effects (e.g., cultural and or demographic similarities among women attending the same salon that influence breast health behavior). To adjust for possible differences between the experimental and control samples due to this clustering, we included the salon site as well as participant age and their interactions in the models.

Results
Stylist training. Twenty-nine stylists completed the training, representing approximately one-third of stylists in the experimental salons at the beginning of data collection. Of those who completed training, 43% were salon owners. Stylists identified themselves as being either African American or Afro-Caribbean (92%); approximately half were born in the Caribbean (52%). Stylists tended to work full-time in the salon (mean hours per week 5 44, sd520) and saw an average of 33 clients per week (sd528). Prior to the training, 96% of participants reported that they felt very willing to discuss breast health with their clients, and the remainder reported that they felt somewhat willing. After the training, 85% reported feeling very willing, 7% reported feeling somewhat willing and the remainder were not willing at all. Following the training, 59% reported that they felt very well prepared to discuss breast health, and 41% reported feeling somewhat

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prepared; 67% reported that they felt very well prepared to provide information about how to detect breast cancer, and 33% felt somewhat prepared. Client-level evaluation. Baseline data included 1,185 clients. Most women identified themselves as being of African ancestry (92%), followed by Hispanic ancestry (7%). Nearly half (47%) of respondents were born outside of the U.S. Of those born outside of the U.S., 74% were from the Caribbean. Overall, 9% of respondents reported a family history of breast cancer, 84% had ever done a BSE, 88% had ever had a CBE, and 53% had ever received a mammogram. Of women reporting age 40 or higher, 89% reported ever having a mammogram. Mean score on the breast health knowledge survey was 62 (619 SD). Over two-thirds of women in the baseline cohort were recruited from experimental salons (N5816 experimental salon participants, N5369 control group participants). These differences were attributable to the balance between experimental and control salons selected for the study design. The baseline sociodemographic characteristics, breast health knowledge, and history of breast health behaviors of these women were similar for those enrolled at experimental and control salons (Table 1). Women completing the anonymous evaluation (N51,210) reported a mean age of 38 years (sd514). After adjusting for salon membership and age, there were no statistically significant differences in breast health behaviors or intentions detected as

Table 1.
PrE-iNTErVENTioN characTErisTics oF womEN rEcEiViNG sErVicEs aT EXpErimENTal VErsUs coNTrol saloNs (N51,185)
Mean age (SD) Self-reported ancestry (%) African Hispanic Other Born in the U.S. (%) Family hx of breast cancer (%) Mean breast health knowledge (SD) Lifetime BSE (%) BSE monthly for last 3 months (%) Lifetime CBE (%) CBE in last 3 months (%) Lifetime mammogram (%) Mammogram in last 3 months (%) Control salon Experimental participants salon participants (N5369) (N5816) p-value 38 (13) 91 7 2 56 10 61 (19) 84.2 25 87 27 50 9 39 (15) 93 6 1 52 9 62 (19) 84 28.3 88 27 54 9 .30 .34 .16 .63 .28 .93 .26 .76 .85 .17 .92

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a function of salon group membership; women at experimental salons were no more likely than those at control salons to report, in the past 3 months, engaging in BSE (37% control, 40% experimental; Adj OR 1.3; Adj 95% CI 0.91.7), receiving CBE (27% control, 29% experimental; Adj OR 1.2; Adj 95% CI 0.91.7), or having a mammogram (13% control, 14% experimental; Adj OR 1.1; Adj 95% CI 0.81.7). There were also no differences reported in intentions to receive a CBE in the next year (90% control, 89% experimental; Adj OR 0.9; Adj 95% CI 0.61.2) or to have a mammogram in the next year (70% control, 74% experimental; Adj OR 1.3; Adj 95% CI 0.91.2). Of the 1,210 respondents, 1,174 (97%) answered questions on exposure to breast health messages at salons. Among women at control sites, 10% reported exposure to breast health messages, as opposed to 37% at experimental sites (OR 5.4, 95% CI 3.7 7.9). As shown in Table 2, exposure to breast health messages was related to a greater likelihood of self-reported BSE (Adj OR51.6) and to greater intentions to have a CBE (Adj OR51.9). There were no statistically significant relationships between exposure to breast health messages and receipt of either CBE or mammogram, nor between such exposure and intention to receive a mammogram.

Table 2.
ANoNYmoUs, cross-sEcTioNal assEssmENT oF brEasT hEalTh iNTENTioNs aNd bEhaViors as a FUNcTioN oF sElF-rEporTEd EXposUrE To brEasT hEalTh mEssaGEs: AdJUsTEd For saloN aNd parTicipaNT aGE (N51,174)
Completed monthly breast self exam for the last 3 months Received a clinical breast exam in the last 3 months Intends to have clinical breast exam in the next year Received a mammogram in the last 3 months Intends to have mammogram in the next year Did not report Reported receiving receiving breast health breast health messages last messages last 3 months 3 months % N 35 26 88 12 70 825 820 827 816 821 % N 48 31 94 16 80 335 337 336 336 336 1.60; 1.202.13 1.20; .941.52 1.87; 1.113.13 1.21; .841.76 1.34; .882.04

Adjusted OR; 95% CI

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Conclusions
Our trial comparing salons randomly assigned to either standard services or provision of breast health messages provides some of the first evidence that exposure to breast health messages by trained stylists can help promote targeted behavioral intentions and behaviors related to breast health screening. This work also builds on the work of others, which has demonstrated that both salons and barbershops are feasible delivery settings for health promotion activities.19,21,22,31,32 This work adds to a growing body of research that suggests that the beauty salon may afford a unique opportunity to provide needed health promotion services to African American women. The evaluation of our program revealed that self-reported exposure to breast health messages in salons was associated with an increased likelihood of reporting having completed monthly breast self-examinations over the past 3 months and to greater levels of behavioral intention to receive a clinical breast examination. We also found that self-reported exposure to health messages in salons was significantly higher for sites where staff had received training through our educational program. These results support the potential of hair salon stylists to have positive influences on the health behavior of their clients, and support the applicability of these models in an urban, minority population. We did not detect differences in behaviors or intentions as a function of whether the client received services at an experimental or control salon. The finding that fewer than 40% of clients at experimental salons received breast health messages from a salon stylist or employee was likely due to several factors. First, we encountered challenges in achieving our goals of having all stylists at experimental salons trained to administer health messages. Although we did achieve our goal of having at least two stylists trained per salon, we were only able to complete training with a third of stylists at experimental salons overall. Incomplete training occurred despite intensive efforts, including payment to stylists and provision of incentives, sending transportation to pick up stylists for training and drop them off at home, and efforts to schedule trainings at multiple times based on the stylists self-reported schedules. Second, although many stylists at experimental salons reported initial willingness to engage their clients in breast health discussions prior to our training, we found that they were actually less willing to do so by the end of the training period, as is evident in the fact that self-reported willingness to discuss breast health actually decreased at the follow-up stylist assessment (96% were very willing to provide messages at baseline, while 85% reported being very willing after the training). In addition, over 30% of our stylists reported feeling less than very well prepared to administer information on breast cancer detection at the end of the training session. This suggests that training of our stylists and their implementation of program activities was not as effective as hoped; it may be that the health messages were too complicated for stylists to implement, or too lengthy to administer on a consistent basis. Research aimed at how best to prepare lay health advisors with the skills and motivation to provide health education on an ongoing basis is needed to help improve programs in this area. In addition, a clearer understanding is needed of how to make these programs feasible on an ongoing basis. We encountered several other challenges in program implementation. First, only 16%

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percent of all salons approached agreed to participate in the study. We felt, however, that this was promising, given that participation was almost entirely motivated by altruism, as we were able to offer little in the way of compensation for participation. Second, during the time of program implementation, several high profile research studies and accompanying news stories placed into doubt the effectiveness of both mammograms and BSE. Thus, historical events may have influenced outcome measures of breast health behaviors. Third, our evaluation only assessed short-term changes in breast health behaviors. Future programs would benefit from assessing whether lay health advisors can affect behavior on an ongoing basis, and assess the need for booster messages. Finally, although we had originally planned a linked follow-up via a telephone interview as an additional evaluation component, we were not able to reach women for this interview at rates that would allow for meaningful analysis of the data. We learned from this process that telephone access was sometimes low and that contact information changed frequently in our population of low-income and immigrant women. Despite these limitations, this program demonstrates that a community-based approach to promoting breast health through the use of lay health advisors in the salon setting is both feasible and potentially effective. We found that among those reporting exposure to such messages, behavior was significantly altered within a population suffering significant health disparities related to breast cancer mortality.

Acknowledgments
This program was supported by the National Cancer Institute (Grant #5R25CA08432404; R. Browne, PI) and the Edna McConnell-Clark Foundation, the United Hospital Fund, and the Riverside Church of New York City. The authors gratefully acknowledge the support of Joan Atchinson, Jamie Hill, William B. Solomon, MD, Ellen McTigue, Mrs. Harriet Mandeville, Nicole Brown, Jean Ward, Bettina Willis, Karen Levine, and members of the Health & Beauty Council.

Notes
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7. Hall IJ, Moorman PG, Millikan RC, et al. Comparative analysis of breast cancer risk factors among African-American women and White women. Am J Epidemiol. 2005 Jan 1;161(1):4051. 8. Pathak DR, Osuch JR, He J. Breast carcinoma etiology: current knowledge and new insights into the effects of reproductive and hormonal risk factors in black and white populations. Cancer. 2000 Mar 1;88(5 Suppl):12308. 9. Tammemagi CM, Nerenz D, Neslund-Dudas C, et al. Comorbidity and survival disparities among black and white patients with breast cancer. JAMA. 2005 Oct 12; 294(14):176572. 10. Davis C, Emerson JS, Husaini BA. Breast cancer screening among African American women: adherence to current recommendations. J Health Care Poor Underserved. 2005 May;16(2):30814. 11. Eley JW, Hill HA, Chen VW, et al. Racial differences in survival from breast cancer. Results of the National Cancer Institute Black/White Cancer Survival Study. JAMA. 1994 Sep 28;272(12):94754. 12. Masi CM, Olopade OI. Racial and ethnic disparities in breast cancer: a multilevel perspective. Med Clin North Am. 2005 Jul;89(4):75370. 13. Jones BA, Patterson EA, Calvocoressi L. Mammography screening in African American women: evaluating the research. Cancer. 2003 Jan 1;97(1 Suppl):25872. Review. Erratum in: Cancer. 2003 Apr 15;97(8):2047. 14. Jones BA, Dailey A, Calvocoressi L, et al. Inadequate follow-up of abnormal screening mammograms: findings from the race differences in screening mammography process study (United States). Cancer Causes Control. 2005 Sep;16(7):80921. 15. Guidry JJ, Matthews-Juarez P, Copeland VA. Barriers to breast cancer control for African-American women: the interdependence of culture and psychosocial issues. Cancer. 2003 Jan 1;97(1 Suppl):31823. 16. Lannin DR, Mathews HF, Mitchell J, et al. Influence of socioeconomic and cultural factors on racial differences in late-stage presentation of breast cancer. JAMA. 1998 Jun 10;279(22):18017. 17. Martin MY. Community health advisors effectively promote cancer screening. Ethn Dis. 2005 Spring;15(2 Suppl 2):S146. 18. Raczynski JM, Cornell CE, Stalker V, et al. Developing community capacity and improving health in African American communities. Am J Med Sci. 2001 Nov; 322(5):26975. 19. Linnan LA, Kim AE, Wasilewski Y, et al. Working with licensed cosmetologists to promote health: results from the North Carolina BEAUTY and Health Pilot Study. Prev Med. 2001 Dec;33(6):60612. 20. Sadler GR, Meyer MW, Ko CM, et al. Black cosmetologists promote diabetes awareness and screening among African American women. Diabetes Educ. 2004 JulAug; 30(4):67685. 21. Browne RC. Most Black women have a regular source of hair carebut not medical care. J Natl Med Assoc. 2006 Oct;98(10):16523. 22. Solomon FM, Linnan LA, Wasilewski Y, et al. Observational study in ten beauty salons: results informing development of the North Carolina BEAUTY and Health Project. Health Educ Behav. 2004 Dec;31(6):790807. 23. Linnan LA, Ferguson YO, Wasilewski Y, et al. Using community-based participatory research methods to reach women with health messages: results from the North Carolina BEAUTY and Health Pilot Project. Health Promot Pract. 2005 Apr; 6(2): 16473.

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24. Brown N, Naman P, Homel P, et al. Assessment of preventive health knowledge and behaviors of African-American and Afro-Caribbean women in urban settings. J Natl Med Assoc. 2006 Oct;98(10):164451. 25. Olson EC, Van Wye G, Kerker B, et al. Take care Flatbush. NYC community health profiles, 2nd ed. New York: New York City Department of Health and Mental Hygiene, 2006; 116. 26. Olson EC, Van Wye G, Kerker B, et al. Take care East New York and New Lots. NYC community health profiles, 2nd ed. New York: New York City Department of Health and Mental Hygiene, 2006; 116. 27. Olson EC, Van Wye G, Kerker B, et al. Take care Central Brooklyn. NYC community health profiles, 2nd ed. New York: New York City Department of Health and Mental Hygiene, 2006; 116. 28. Bandura A. Health promotion by social cognitive means. Health Educ Behav. 2004 Apr;31(2):14364. 29. Bandura A. Social foundations of thought and action: a social cognitive theory. Englewood Cliffs, NJ: Prentice Hall, 1986. 30. McCance KL, Mooney KH, Smith KR, et al. Validity and reliability of a breast cancer knowledge test. Am J Prev Med. 1990 MarApr;6(2):938. 31. Hart A Jr, Bowen DJ. The feasibility of partnering with African-American barbershops to provide prostate cancer education. Ethn Dis. 2004 Spring;14(2):26973. 32. Hess PL, Reingold JS, Jones J, et al. Barbershops as hypertension detection, referral, and follow-up centers for black men. Hypertension. 2007 May;49(5):10406.

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