Methods

In March 2013, the Office of Health Equity, in partnership with the cosmetology section of the Arkansas Department of Health, contacted minority-owned barbershops, beauty shops, and barber/beauty colleges and invited them to an educational session where CVD risk factors (eg, hypertension, diabetes, obesity, tobacco use) and their effect on racial/ethnic minority communities were discussed. The ARBBS initiative was introduced to the business owners, and they were asked if they would want their shops or colleges to be screening locations. To qualify as a screening site, a business was required to meet a threshold of at least 50 clients on a given Saturday, 5 to 10 barbers or beauticians working on a given Saturday, and the capacity to host 18 to 36 volunteer team members without disrupting their flow of business. All locations that met the criteria and whose owners were willing to participate signed a form approving their businesses to serve as health screening locations. This study was approved by the institutional review board at the University of Arkansas for Medical Sciences. The study was conducted in 14 counties from February 2016 through June 2019 (the study period).

Volunteer recruitment and training

Medical and nonmedical volunteers were recruited from local universities and colleges, the health department, local hospitals, and nonprofit organizations in the community. Volunteers recruited included physicians, advanced nurse practitioners, registered nurses, dietitians/nutritionists, certified health education specialists, public health practitioners, nursing students, pharmacy students, medical students, public health students, Spanish interpreters, and laypeople. Recruitment emails were sent out to various listservs, and flyers were printed and distributed to colleges and organizations.

All volunteers were required to attend a mandatory 2-hour standardized training before participating in the health screenings. The training included a review of a participant survey, protocols for each volunteer role, and instructions on how to administer a survey properly. Twenty-one training sessions were conducted during the 4 years, with 1,012 total volunteers in attendance.

Participant recruitment

Study participants were recruited from the clientele of participating beauty shops and barbershops and via bilingual (English and Spanish) radio, internet, newspaper, and television advertisements. People who agreed to participate in the health screening signed a consent form that detailed the types of screening to be performed as well as their rights to confidentiality and privacy. All participants had to be aged 18 years or older.

Screening process

The screening consisted of 8 checkpoints: 1) registration, 2) blood pressure measurement (via sphygmomanometer), 3) blood glucose and cholesterol measurement (via finger stick), 4) education on tobacco cessation, 5) education on heart disease and stroke, 6) screening for body mass index (BMI) (height and weight were measured) and education on proper nutrition and physical activity, 7) counseling and medical referrals, and 8) posttest survey. A pretest survey was administered at checkpoints 2 through 5. Volunteers were assigned to checkpoints on the basis of their training and expertise. Health educators and health practitioners conducted the educational components on CVD (heart attack and stroke), CVD risk factors (high blood pressure, high cholesterol, diabetes, and tobacco use), and proper physical activity and nutrition habits. Participants received counseling and medical referrals at checkpoint 7 from volunteers who were either medical doctors or advanced nurse practitioners. The screening process took approximately 45 minutes to an hour to complete.

Participants who had abnormal screening results for hypertension, diabetes, or cholesterol (Box; [20,21]) were referred to medical providers or charitable clinics for further evaluation and follow-up. Participants who had a primary care physician were referred to seek treatment from their provider. Participants who did not have a primary care physician were referred to charitable clinics or medical providers in their area, regardless of their health insurance status. Participants who had a BMI of 25.0 kg/m² or higher were referred to health care providers for support with proper nutrition and physical activity.

Pretest and posttest. A pretest questionnaire and posttest questionnaire were used to obtain data on demographic characteristics, access to care, chronic disease risk levels, knowledge of chronic diseases, and medical referral status. Trained volunteers administered a paper-and-pencil bilingual (English and Spanish) survey to each participant during checkpoints 2 through 5 (pretest) and at checkpoint 8 (posttest). Each questionnaire had a unique identification number. Survey questions were adapted from the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System. The pretest questions asked about demographic characteristics (age, sex, race/ethnicity, education) and whether the participant had a personal physician and health insurance. In addition, both the pretest and posttest survey assessed knowledge of chronic disease with the following multiple-choice questions: “What should a normal blood pressure be?” Responses for “top number” were less than 200, 130, 140, greater than 150, or don’t know. Responses for “bottom number” were less than 80, 90, 100, greater than 120, or don’t know. “What is a normal total cholesterol level?” Responses were less than 200, 250, 300, 400, or don’t know. Two questions were in true–false format: 1) “The following are some symptoms of a stroke” Responses were facial droop, slurred speech, weakness in arm or leg. 2) “The following are some symptoms of a heart attack” Responses were chest pain; nausea/flu-like symptoms; neck, back, and jaw pain; shortness of breath). Finally, “What is the first thing you should do if you thought someone was having a stroke or heart attack?” Responses were “take them to the hospital,” “Tell them to call their doctor,” “Call 911,” “Call their spouse or family member,” and “don’t know.”

Medical referrals When a participant was referred for medical follow-up, the study team initiated a new form. This bilingual medical referral form recorded the participant’s contact information and screening results and was used to track people who were referred for follow-up medical care. The unique survey number was transferred to the medical referral form if the participant received a referral. The nurse coordinator, a staff member of the Office of Health Equity, conducted follow-up telephone calls within 30 days after the screening and every 3 months thereafter for a year. During the follow-up calls, participants were asked if they kept their medical appointments, started new medications, had a change in medication, changed their dietary habits, started exercising, or quit tobacco use (if applicable); their responses were self-reported. We tracked the number of participants who kept their medical appointments and the number of participants who agreed to return to the health screening the following year. The nurse coordinator also noted any other information that the participants provided, such as whether they had received any surgical interventions as a result of the screening intervention.

Data analysis Our analytic sample consisted of 1,833 participants. We used descriptive statistics to summarize data on the demographic characteristics of the participants, their access to care (health insurance and personal physician), knowledge of disease, and screening results. We used data obtained from medical referral and participant follow-up forms to examine compliance (eg, keeping physician appointments or taking hypertension medication) and management of risk factors (eg, exercise, proper diet to reduce obesity, smoking cessation) among participants who received referrals. We conducted χ² tests to determine whether the education received during the screening event improved the number of correct answers on the posttest. We managed all data obtained from the health screenings and follow-up telephone calls in REDCap version 9.1.20 (Vanderbilt University). We used SAS version 9.4 (SAS Institute Inc) to conduct all analyses.