David C. Lee, MD, on the “Barbershop Intervention” for Undiagnosed Diabetes in Black Men
A promising new intervention taking place in barbershops owned by black individuals may help improve racial/ethnic health disparities related to diabetes, according to new findings published in JAMA Internal Medicine.
The study indicated that an intervention involving rapid point-of-care hemoglobin A1c (HbA1c) testing in black-owned barbershops could help identify undiagnosed diabetes and prediabetes among black men. This patient population is known to experience diabetic complications at disproportionate rates and are less likely to survive into their 70s compared with men in other racial/ethnic groups.
A total of 895 black male patrons of barbershops in Brooklyn, New York, were asked to participate in the study. Of these men, 312 (34.9%) agreed to be screened after encouragement from their barber, and 290 (32.4%) were successfully tested. Twenty-six (9.0%) participants had an HbA1c level of 6.5% or higher, signaling the presence of diabetes, and 82 (28.3%) participants had an HbA1c level between 5.7% and 6.4%, indicating prediabetes. The prevalence of undiagnosed diabetes in the study population was found to be approximately 2.5 times higher than that of New York City residents overall (9.0% vs an estimated 3.6%).
Men with an HbA1c level of 5.7% or higher were counseled on the importance of dietary modifications, exercise, and medical management, and also were given contact information for local primary care clinics.
The findings from the intervention are important because the diagnosis of diabetes is often delayed, especially among black men without a regular primary care provider, the authors of the study wrote. The barbershop intervention, which was also recently shown to aid in diagnosing hypertension among black men, may be especially effective in reaching these patients because barbershops are places of trust among black men, the authors added.
Endocrinology Consultant discussed the implications of the present study further with study author David C. Lee, MD, assistant professor in the Ronald O. Perelman Department of Emergency Medicine and Department of Population Health at New York University (NYU) Langone Health.
Endocrinology Consultant: What led you to conduct the intervention in barbershops? Why are barbershops an important source of trust among black men, and how could this trust have a positive impact on health outcomes?
Dr Lee: My colleagues at NYU, including Joseph Ravenell, MD, and Stephen Wall, MD, have had a long history of reaching out to black men using barbershops as a community-based setting to promote good health outcomes. There are good studies that demonstrate that barbershops owned by black individuals may be a good place to help treat patients with hypertension, and others have looked at other ways to promote good health outcomes in other areas.
It is my understanding that barbershops have long been a meeting space where men come to talk about all sorts of issues that affect their lives, including their health. Indeed, we found that several men were willing to be screened because of their barbers' influence and were willing to engage with us because we had an existing relationship with their barbers.
This kind of trust is essential in any relationship, especially in the doctor-patient relationship. I think too often we are ready to dismiss people who think differently than we do instead of taking the time to understand how we can help patients in the context of their concerns and priorities.
Endocrinology Consultant: How might this intervention help break down socioeconomic barriers that have traditionally stood in the way of good health outcomes among black men? How might it improve diagnosis and treatment of diabetes among populations that are traditionally harder-to-reach?
Dr Lee: Diabetes screening is especially important among black men because, unfortunately, they have some of the highest rates of diabetic complications and early diabetes-related death. Not only are they at risk for developing diabetes at a much earlier age, but their diabetes is probably diagnosed too late.
Often, our use of health care is in response to symptoms being experienced. However, many chronic diseases are asymptomatic until the disease has been damaging the body for years. While health care access and financial difficulties definitely exacerbate these disparities, we know that some people are at risk of having diabetes at an early age, and we need to figure out better methods of identifying and screening in these high-risk groups.
Endocrinology Consultant: What do you hope endocrinologists and other clinicians treating diabetes take away from this study?
Dr Lee: For clinicians, I hope that we do a better job of screening high-risk patients for diabetes at an early age. It is very easy to think of a male in his 30s as someone who probably does not have diabetes. However, it was surprising to us how many young men we found with diabetes in this study.
Furthermore, as an emergency medicine physician, I know that the clinical environment is often rushed. However, if we are too ready to label patients as non-compliant because they do not follow our instructions, I hope we remember that it is not that easy to change health behaviors. Even I, as a physician, struggle with adding good health habits in my own life. It is important to engage patients in their specific circumstances and understand their health beliefs even if these beliefs are different from our own.
Endocrinology Consultant: What are the next steps in terms of future research?
Dr Lee: Now that we have identified these black men with previously undiagnosed diabetes and prediabetes, we need to determine the best approach for treating them and helping them improve their health habits. In addition, we need to understand whether barbershops are the best setting for this type of intervention, or whether there could be other community-based settings that could also be used to promote early diabetes screening among black men and other minority groups.
Osorio M, Ravenell JE, Sevick MA, et al. Community-based hemoglobin A1c testing in barbershops to identify black men with undiagnosed diabetes [Published online January 27, 2020]. JAMA Intern Med. doi:10.1001/jamainternmed.2019.6867.