The US is currently experiencing a Mental and Behavioral Health (MBH) crisis with projections suggesting an increasing incidence. Approximately 1 in 5 (18.5%) US residents have been diagnosed with an MBH disorder. Access to MBH care is lower than other types of care and is particularly so compared with other chronic conditions. As with many other medical conditions, screening, early detection, and effective and ongoing treatment can have a profound impact on quality and quantity of life. Unfortunately, with MBH disorders, the disorders themselves can impair one’s ability to seek out and successfully manage treatment. MBH disorders have the least number of patients receiving care, the longest delays between diagnosis and treatment, and the most limited follow-up.
The prevalence of MBH disorders is similar between Whites and Blacks, but < 25% of blacks seek MBH care due to perceived stigma, health system distrust, risk of misdiagnosis and low provider cultural sensitivity, further hindered by a shortage of black MBH providers. Increasing access to both black MBH providers and MBH providers who have cultural knowledge and sensitivity to work in black communities is essential for narrowing this disparity. In black communities, the black barbershop has long served an important social and cultural purpose. It has been a safe gathering place for black men. It is where people have received their news, registered to vote, and shared their personal struggles. The barber is not just the person who cuts hair but is also a confidant. This connection between barber and client in black communities places the barber in a unique position to be a strong partner and leader in increasing MBH literacy, specifically among black men.
Wicked Problem Description:
Our initiative is primarily focused in the Southeast area of the District of Columbia (DC) – a predominantly black urban community. It also represents one of the most under-resourced in the nation; yet, just a few miles away there are some of the nation’s wealthiest communities. This area is also designated as a medically underserved area and MBH professional shortage area. In DC, blacks are twice as likely than other races to report serious MBH problems especially if they live in poverty (household income less than $15,000) and did not finish high school. In the Ward 8 area of Southeast DC, more than 95% of the population is Black, 38% of the population lives in poverty and only 55% complete high school. This is especially unfortunate because there is evidence that common MBH disorders such as depression and anxiety are distributed according to a gradient of economic disadvantage across society, and the poor and disadvantaged and suffer disproportionately from common MBH disorders and their adverse consequences. Furthermore, studies show that under-resourced communities are less likely to receive the effective treatments that are available for MBH disorders and if they do, their efficacy is often reduced due to a lack of attention to the social determinants of mental health such as unstable housing, food insecurity and lack of transportation.
The purpose of the MHI-STREET Barbershop Embedded Education (BEE) initiative is to positively influence mental and behavioral health (MBH) wellness in the Southeast District of Columbia (DC) through increasing the MBH literacy of barbers and their clients. MHI-STREET is engaging black barbers as a historically trusted community resource to deliver positive and accurate MBH messaging to their predominantly black male clients and connect them to services. The ‘practice of educating people through everyday interpersonal encounters within organizations that exist for non-educational purposes’ is a recognized innovation in governance called “embedded education.”
Improved MBH literacy among Southeast DC barbers and their clients to mitigate misinformation and stigma and encourage connection to care.
DATA COLLECTION AND ANALYSIS
- Obtained access to locally relevant data to inform all aspects of the initiative
- Developed, administered and analyzed a 200-patient knowledge, behavior and attitude survey of MBH in Ward 8’s safety-net hospital
- Developed, administered and analyzed a survey for private Ward 8 Medicaid primary care providers on knowledge and practices in MBH
- Compiled inventory of Ward 8 MBH and social resources as requested by stakeholders
- Collaborated with academia to create geographic “hotspot” maps in Ward 8 to find a correlation between emergency room use and MBH diagnoses
- Collaborated as a co-investigator on NIH-funded project at the Ward 8 safety-net hospital to evaluate the integration of social determinants of health and MBH in risk adjustment models
- Convened MBH community informant sessions with barbers and faith leaders
- Precepted several MBH graduate student efforts within existing academic partnerships
- Built an active and engaged network of professionals, community-based leaders and organizations that are invested in health.
- Convened the MBH Sub-Committee Advisory Group of the Ward 8 Health Council. This was one of MHI-STREET’s earliest successes allowed access to the insight and knowledge of thought leaders. Through active community collaborations and awareness of local resources, it was determined that maximal community impact, reach and influence in MBH would be best achieved through anchor institutions. The group selected barbershops as untapped anchor institutions.
- Convened several Ward 8 local faith leaders for an informational session and connected with the Mental Health Association in New Jersey through their PEWS program (Promoting Emotional Wellness and Spirituality).
- Convened a core group of barbers to serve as an advisory team for the BEE.
- Consulted entities across several states and abroad around best practices for barbershop programming. In the United Kingdom, consulted specifically with the Lion’s Den, a barber shop mental health program recognized by Prime Minister Theresa May.
- Created a culturally relevant MBH BEE curriculum for embedded education in barber shops as a collaborative effort with community partners in Year 1. In Year 2 further expanded the curriculum to better address topics relevant to the Ward 8 community.
- Selected a master barber in the community to recruit the first cohort of barbers for MBH training. In Year 2 piloted the MBH curriculum to these barbers.
- Received a Pilot Award from George Washington University’s Nashman Center of Civic Engagement for the BEE initiative.
- Presented the BEE initiative at George Washington’s School of Nursing Community Engagement Conference.
- Conducted a post-training evaluation session with the first barber cohort.
- Connected with The Confess Project, an Arkansas-based national grassroots Barbershop Program that engages men about MBH.
- Connected with DC Government Small Business Development to explore formation of a certified business enterprise.
- Explored the addition of financial literacy to the BEE to address the economics as a social determinant of MBH.
- Selected for the 2018 Leadership of Greater Washington Signature Program which recognizes multi-sectoral leaders in the region.
- Developed a social marketing strategy for MHI-STREET and the BEE.
- Collaborated with a marketing consultant and designer to brand MHI-STREET and BEE
- Received social entrepreneurship training with Seed Spot at Booz Allen Hamilton. Pitched the BEE to potential investors. Received feedback from community mentors. Won the “Growth Award” for the business idea that most evolved during the training.
DATA COLLECTION AND ANALYSIS – Finalize data collection and analysis
- Convene informant sessions of barbers’ clients and evaluate their baseline MBH literacy, barriers to utilization of MBH services and need for services to address social determinants of MBH.
COMMUNITY ENGAGEMENT – Expand the reach of the BEE and pursue the sustainability of effort
- Modify the MBH BEE curriculum for use in different environments
- Train student barbers in four DC barbering schools on the BEE curriculum
- Convene quarterly “barbershop talks” led by community residents in collaboration with the Confess Project
- Explore the creation of an app-based MBH continuing education course to fulfill barber biennial licensing requirements
- Explore the establishment of a local barbering school with a focus on MBH wellness
- Form a for-profit or non-profit entity to continue MHI-STREET post-Clinical Scholars
SOCIAL MARKETING – Address societal norms around MBH though targeted social marketing
- Continue to develop a social media platform and social marketing materials with positive MBH messaging and resources targeted to barbers and their clients.
Several multi-sectoral partnerships with academia, advocacy, banking, retail and local government.
The evaluation of the initiative includes the generation of a mixed-method report on the knowledge, attitudes and behavior of patients, providers and community residents; utilization of Kirkpatrick’s Four Levels of Learning Evaluation framework to measure the effectiveness of the barber training; and utilization of social media analytics tools to guide ongoing social media marketing strategy.