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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 3.7–7.9). Self-reported exposure to stylist-delivered messages was associated with improved breast self-examination rates (OR 1.6, 95% CI 1.2–2.1) and with greater intentions to have a clinical breast examination (OR 1.9, 95% CI 1.1–3.3). 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): 216–226.
the beauty salon affords a promising setting for health promotion efforts and for recruiting lay health advisors.4 greater risk for obesity. 217 A lthough breast cancer incidence is lower for African American women in the United States than for White women. the North Carolina BEAUTY and Health Project demonstrated both that salon stylists often engage naturally in health-related discussions.7.5 more aggressive breast carcinoma tumors. and documented the willingness of employees at salons to deliver health messages to customers. Methods Respondents. many women within the African American community regularly visit hair salons. 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. Wright. Randomization procedure. presenting an opportunity for widespread and regular dissemination of health messages to this population. a phenomenon that may be due in part to lower utilization of screening methods. that disparities in timing of diagnosis are also a major contributor. King. et al. such as regular mammography. Homel.19.24 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.21 For instance.Wilson.1 the age-standardized death rate for breast cancer is significantly higher. low-income areas of Brooklyn.23 In preliminary studies of clients at hair salons in our service area.16 The use of lay health advisors to promote behavior change represents one promising approach to meeting this need. Clients receiving services at experimental and control salons were eligible to participate in program evaluation activities.8 and the presence of co-morbid conditions such as diabetes and hypertension. Crown Heights. and accessible to those in greatest need of services. Bedford-Stuyvesant. acceptable.10 African American women are typically first diagnosed with cancer at a later stage than White women are. New York.3 It has been posited that these differences are related to a number of factors. effective. We targeted several neighborhoods (East Flatbush. Flatbush. and inadequate follow-up rates related to abnormal findings from screening tests.18 For the purpose of reaching African American and AfroCaribbean women.17. Feldman. . New York. and breast self-examination among African American women falls below American Cancer Society recommendations. there are few programs that are culturally appropriate. clinical breast examination.9 It is clear. we found that women had a need for improved knowledge regarding breast cancer.2.11–14 Despite widespread awareness of the need to promote breast cancer screening behaviors in communities of color. including lower likelihood of African American women receiving breast conserving surgery.6 higher reproductive risk factors. and has been shown to be useful in promoting breast cancer screening practices. 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.20 In addition. Fraser-White.22. however. Adherence to mammography. and East New York) in Brooklyn.15.
Breast health recommendations at the time of study start-up included monthly breast self-exams. Although we calculated that implementing intervention activities in a smaller number of salons would have yielded a sample size sufficient to conduct our analyses. Intervention development and implementation. Afro-Caribbean. Stylists were trained to conduct tailored and culturally sensitive counseling that would encourage clients to engage in breast health behaviors. faculty at the State University of New York Downstate Medical Center. the Health and Beauty Council. and members of the community advisory group for this program. each salon provided services to 200 clients. The Health and Beauty Council consists of local community health leaders. monitoring of progress toward program goals. 12 for no-treatment control sites) from the target neighborhoods using a random number generator. Randomization was conducted after proprietor agreement to take part in the study. and Hispanic) and are more likely to live below the poverty line than are residents of New York City overall. annual clinical breast exams. residents of these neighborhoods are minority group members (African American.29 The training was designed to promote skills and self-efficacy for conducting counseling with clients.28. including salon owners. These partners worked together on defining the approach to programming and evaluation. We contacted the proprietor of each selected salon to assess willingness to participate as either an experimental or control salon site. and interpretation of results. We randomly selected 40 salons (28 for intervention activities. we randomly selected the next salon from that neighborhood. Partners for intervention development and evaluation included the Director and members of the Arthur Ashe Institute for Urban Health. 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. These salons serve a large number of clients. the content and wording of training sessions and evaluation instruments. 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.218 Hair salon stylists as breast cancer prevention advisors as a focus for program activities. academic centers. and businesses in Brooklyn. Salons were excluded from program activities if the owner was a member of the Health and Beauty Council. Predominantly. board members and leaders of local media outlets and foundations. 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. methods for data collection and survey content. we approached 257 salons in order to reach our goal of 40 salons. we estimate that on average. In total. Both the content of the training and the messages to be administered to clients by stylists were informed by Social Cognitive Theory.25–27 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. Based on estimates of client numbers reported at participating salons and on logs of customer census taken periodically by study staff at these salons. over a 3-month period. When a salon proprietor refused to participate. and routine mammography for women 40 years of age and older. breast cancer survivors and other health care advocates. and academic partners. Components of this interactive training targeted (1) improved communications skills related to breast health through role-playing and .
King. and ongoing support and technical assistance for stylists and salon staff by staff at the Arthur Ashe Institute for Urban Health. 219 modeling of interactions. perceived preparedness to provide health education regarding breast cancer detection methods. The baseline survey included questions on sociodemographic characteristics. and willingness to promote breast health screening with clients. In order to assess characteristics of participants at experimental and control salons.00. Participants were not compensated for completion of surveys. Stylists completed a brief. Client assessment. Salon stylists also were given written materials to provide to clients on where to receive services for breast cancer detection and treatment. and lasted for three months at each salon. In addition. and knowledge related to breast cancer screening and breast cancer. (3) improvement in knowledge and the ability to explain issues involved in the etiology. Stylist training was implemented in waves. 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. stylists were provided $30 cash to cover time and expense in traveling to the site of trainings. given preliminary information that salon clients receive services at least on a monthly basis. et al. 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. detection. At follow-up. Family history of . Wright. Data collection and measures. staffadministered assessment both before and immediately following the stylist training. a reference handbook related to key information provided in the training. However. and (4) skills-building related to tailoring messages to clients based on their receptiveness to discussing and engaging in breast health behaviors. Stylists were compensated for their participation in the training with professional development classes by a renowned hair stylist. ended in April 2004. we had implemented a third component of the evaluation. based on planned initiation of intervention activities in that salon. clinical breast examination (CBE). two-hour workshops. Homel. Each stylist was provided with contact information for program staff so that any questions could be answered as needed. given that the retention rate for this follow-up telephone interview was only 20%. and treatment of breast cancer. Originally. we assessed perceived preparedness to discuss breast health. The first occurred prior to onset of program activities at the salons. Fraser-White. prevention. these linked data were not analyzed further. Stylist training. and mammograms. Implementation of the program at experimental salons began in January 2002. The hair stylist donating these classes was a member of the Health and Beauty Council. These classes were valued at approximately $800. 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). Feldman. we analyzed two cross-sectional assessments of women. family history of breast cancer. Variables assessed at baseline included demographic characteristics and willingness to provide breast health promotion with clients. (2) sensitization to cultural and practical issues involved in interactions with customers. A second anonymous assessment occurred after 1 to 3 months initiation of program services. Training for each stylist involved two. lifetime behaviors and behaviors in the past 3 months related to breast self-examination (BSE).Wilson.
78. To assess program outcomes in the follow-up survey. representing approximately one-third of stylists in the experimental salons at the beginning of data collection. whether they had received a mammogram in the last 3 months. To adjust for possible differences between the experimental and control samples due to this clustering. Chronbach’s alpha for this scale within our population was . However. and 41% reported feeling somewhat . regardless of attendance at either an experimental or control salon. whether they intended to have a CBE in the next 12 months. sd520) and saw an average of 33 clients per week (sd528). 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. 96% of participants reported that they felt very willing to discuss breast health with their clients. 43% were salon owners. We also assessed breast cancer knowledge through an 18-item scale previously shown to be predictive of breast cancer screening behaviors. Twenty-nine stylists completed the training. or a sister had ever been diagnosed with breast cancer. Prior to the training. and the remainder reported that they felt somewhat willing. cultural and or demographic similarities among women attending the same salon that influence breast health behavior). Of those who completed training.30 Each item was scored as correct or incorrect on the scale.. We did not ask women about actual appointments for CBE or mammography.220 Hair salon stylists as breast cancer prevention advisors breast cancer was assessed in terms of whether the salon client’s mother. After the training. and a total score was assigned based on the percentage of items that were correctly answered. Stylists identified themselves as being either African American or Afro-Caribbean (92%). The effect of the study intervention on the measures of breast health behavior was examined using general estimating equations logistic regression models (GEE). The last questions on the survey asked the woman’s 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. Following the training. indicating adequate reliability. Results Stylist training. we also compared outcomes based on whether or not women reported being exposed to breast health messages. a daughter. 85% reported feeling very willing. as our planning group was concerned that asking for such information might compromise a client’s sense of anonymity.g. approximately half were born in the Caribbean (52%). 59% reported that they felt very well prepared to discuss breast health. but instead focused on behavioral intentions to receive these services. we included the salon site as well as participant age and their interactions in the models. an approach that adjusted for any clustering effects (e. if they had had a CBE in the last 3 months. Stylists tended to work full-time in the salon (mean hours per week 5 44. and whether they intended to have a mammogram in the next 12 months. 7% reported feeling somewhat willing and the remainder were not willing at all. we examined the impact of participation in experimental versus control salons. Data analysis. Women were asked whether they had conducted a monthly BSE for the last 3 months.
221 prepared.S. Mean score on the breast health knowledge survey was 62 (619 SD).30 . 88% had ever had a CBE. (%) 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. and 33% felt somewhat prepared. 74% were from the Caribbean.26 .63 .S. Wright. Of women reporting age 40 or higher. Most women identified themselves as being of African ancestry (92%). 67% reported that they felt very well prepared to provide information about how to detect breast cancer. King.S.185) Mean age (SD) Self-reported ancestry (%) African Hispanic Other Born in the U.185 clients. N5369 control group participants). Overall. followed by Hispanic ancestry (7%). 9% of respondents reported a family history of breast cancer. 89% reported ever having a mammogram.210) reported a mean age of 38 years (sd514).. Homel. Women completing the anonymous evaluation (N51.2 25 87 27 50 9 39 (15) 93 6 1 52 9 62 (19) 84 28.17 . These differences were attributable to the balance between experimental and control salons selected for the study design.76 . Over two-thirds of women in the baseline cohort were recruited from experimental salons (N5816 experimental salon participants.Wilson.34 . Baseline data included 1.3 88 27 54 9 . breast health knowledge.85 . et al. and history of breast health behaviors of these women were similar for those enrolled at experimental and control salons (Table 1).16 . Client-level evaluation. there were no statistically significant differences in breast health behaviors or intentions detected as Table 1. Feldman. and 53% had ever received a mammogram. After adjusting for salon membership and age. The baseline sociodemographic characteristics. PrE-iNTErVENTioN characTErisTics oF womEN rEcEiViNG sErVicEs aT EXpErimENTal VErsUs coNTrol saloNs (N51.28 . 84% had ever done a BSE.93 . Nearly half (47%) of respondents were born outside of the U. Of those born outside of the U.92 . Fraser-White.
34. 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. . Adj OR 1.20. 29% experimental. 1.20–2. engaging in BSE (37% control.88–2. or having a mammogram (13% control. 1.7).174 (97%) answered questions on exposure to breast health messages at salons. Table 2. 95% CI .7).9–1. Adj OR 1. .210 respondents.9).94–1. Among women at control sites. ANoNYmoUs. 40% experimental. Adj 95% CI 0. As shown in Table 2.174) 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 1.04 Adjusted OR.87.9.7– 7.9–1. receiving CBE (27% control. as opposed to 37% at experimental sites (OR 5. 95% CI 3.3. Adj OR 1. Adj 95% CI 0. Adj OR 0. There were no statistically significant relationships between exposure to breast health messages and receipt of either CBE or mammogram. Adj OR 1.6) and to greater intentions to have a CBE (Adj OR51. .84–1. There were also no differences reported in intentions to receive a CBE in the next year (90% control.76 1.13 1.13 1.21.2). Adj 95% CI 0.1.8–1. 14% experimental.11–3.60. 74% experimental. in the past 3 months. women at experimental salons were no more likely than those at control salons to report.222 Hair salon stylists as breast cancer prevention advisors a function of salon group membership. 1. nor between such exposure and intention to receive a mammogram.52 1. exposure to breast health messages was related to a greater likelihood of self-reported BSE (Adj OR51. Adj 95% CI 0. 10% reported exposure to breast health messages.4.2.9).7).6–1.9–1. Adj 95% CI 0.2) or to have a mammogram in the next year (70% control.3. Of the 1. 89% experimental.
We encountered several other challenges in program implementation. 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. and support the applicability of these models in an urban. These results support the potential of hair salon stylists to have positive influences on the health behavior of their clients. or too lengthy to administer on a consistent basis.Wilson. 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. we were only able to complete training with a third of stylists at experimental salons overall. Second. This work also builds on the work of others. 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.31. minority population. 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. Although we did achieve our goal of having at least two stylists trained per salon. This suggests that training of our stylists and their implementation of program activities was not as effective as hoped. while 85% reported being very willing after the training). Incomplete training occurred despite intensive efforts. Wright. including payment to stylists and provision of incentives. 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. we found that they were actually less willing to do so by the end of the training period. only 16% . Feldman. and efforts to schedule trainings at multiple times based on the stylists’ self-reported schedules. First.22. First. 223 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. et al. sending transportation to pick up stylists for training and drop them off at home. In addition. a clearer understanding is needed of how to make these programs feasible on an ongoing basis. which has demonstrated that both salons and barbershops are feasible delivery settings for health promotion activities. Homel. King. We did not detect differences in behaviors or intentions as a function of whether the client received services at an experimental or control salon. In addition.21. it may be that the health messages were too complicated for stylists to implement.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. although many stylists at experimental salons reported initial willingness to engage their clients in breast health discussions prior to our training. Fraser-White. 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. we encountered challenges in achieving our goals of having all stylists at experimental salons trained to administer health messages.19.
Cancer statistics. 3. 2005 Mar 16. Mrs. and the Riverside Church of New York City. Ward E. Bettina Willis. Thus. and End Results) Program population-based study. Murray T. Jamie Hill. Teal CR. Epidemiology. Howe CL. 2005 Jan–Feb. Erratum in: CA Cancer J Clin. Browne. Jemal A. Chlebowski RT.224 Hair salon stylists as breast cancer prevention advisors percent of all salons approached agreed to participate in the study. 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. Cancer. Jones BA. Chen Z. 2004 Sep 15. 2. Cancer. Joslyn S.55(1):10–30. our evaluation only assessed short-term changes in breast health behaviors. Notes 1. The authors gratefully acknowledge the support of Joan Atchinson. 6. Solomon.162(17):1985–93. MD. William B. Finally. during the time of program implementation. and assess the need for booster messages. et al. Bernstein L. as we were able to offer little in the way of compensation for participation.97(1 Suppl):222–9.94(7):490–6. historical events may have influenced outcome measures of breast health behaviors. Ethnicity-related variation in breast cancer risk factors. et al. however. 2002 Apr 3. Li FP. Cancer survival among US whites and minorities: a SEER (Surveillance. CA Cancer J Clin. 2003 Jan 1. We felt. et al. socioeconomic status. 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. African-American/White differences in breast carcinoma: p53 alterations and other tumor characteristics. Karen Levine. Anderson GL. 4. given that participation was almost entirely motivated by altruism.55(4):259. Roberts C. J Natl Cancer Inst. Ellen McTigue. 97(6):439–48. Nicole Brown. Jean Ward. and breast cancer treatment and survival. behavior was significantly altered within a population suffering significant health disparities related to breast cancer mortality. we were not able to reach women for this interview at rates that would allow for meaningful analysis of the data. the United Hospital Fund. although we had originally planned a linked follow-up via a telephone interview as an additional evaluation component. R. 5. . Hankey BF. PI) and the Edna McConnell-Clark Foundation. Clegg LX. Future programs would benefit from assessing whether lay health advisors can affect behavior on an ongoing basis. et al. and members of the Health & Beauty Council. 2002 Sep 23. that this was promising. Third. Acknowledgments This program was supported by the National Cancer Institute (Grant #5R25CA08432404. Despite these limitations. We found that among those reporting exposure to such messages. Race. Arch Intern Med. several high profile research studies and accompanying news stories placed into doubt the effectiveness of both mammograms and BSE. J Natl Cancer Inst. Given CW. Bradley CJ. Second. 101(6):1293–301. Ethnicity and breast cancer: factors influencing differences in incidence and outcome. Kasl SV. et al. 2005 Jul–Aug. Harriet Mandeville. 2005.
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