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Hea th Education Development of a barbershop-based communication intervention Cheryl L. Holt Department of Public and Community College Park, Maryland, USA Theresa A. Wynn Division of Preventive Medicine, Birmingham, Alabama, USA

Health, School of Public Health,

School of Medicine,

University

University

of Alabama

cancer

of Maryland,

at Birmingham,

Ivey Lewis Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA Mark S. Litaker Birmingham, Alabama, School of Diagnostic Sciences, University of Alabama at Birmingham, Sanford Jeames Donahue Institute,

University

of Massachusetts,

Francine Huckaby School of Public Health, University Leonardo Stroud

of Alabama

Hadley, Massachusetts, at Birmingham,

USA

Birmingham,

Epidemiology and Applied Research Branch, Division of Cancer Prevention Centers for Disease Control and Prevention, Atlanta, Georgia, USA Penny L. Southward Division of Preventive Medicine, Birmingham, Alabama, USA Virgil Simons The Prostate Net, Hackensack, Crystal Lee Division of Preventive Medicine, Birmingham, Alabama, USA Louis Ross

School of Medicine,

Alabama,

USA

and Control,

University

of Alabama

at Birmingham,

University

of Alabama

at Birmingham,

New Jersey, USA School of Medicine,

Centers for Disease Control and Prevention, Theodies Mitchell

Atlanta,

Georgia,

USA

Centers for Disease Control and Prevention,

Atlanta,

Georgia,

USA

USA

---------------------------~

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Cancer communication intervention

Development of a barbershop-based cancer• • •• communIcatIon InterventIon

213

Cheryl 1. Holt, Theresa A. Wynn, Ivey Lewis, Mark S. Litaker, Sanford Jeames, Francine Huckaby, Leonardo Stroud, Penny 1. Southward, Virgil Simons, Crystal Lee, Louis Ross and Theodies Mitchell (Affiliations are shown at the end of the paper)

Abstract Purpose - Prostate and colorectal cancer (CRe) rates are disproportionately high among African-American men. The purpose of this paper is to describe the development of an intervention in which barbers were trained to educate clients about early detection for prostate and CRe. Design/methodology/approach - Working with an advisory panel of local barbers, cancer survivors and clients, educational materials are developed and pilot tested through use of focus groups and cognitive response interviews. Findings - The advisory panel, focus groups, and interviews provide key recommendations for core content, intervention structure, and evaluation strategies. The men suggest a variety of things they want to know about prostate cancer, however the perceived need for CRCinformation is much broader, suggesting a b..nowledge gap. The men prefer print materials that are brief, use graphics of real African-American men, and provide a telephone number they can call for additional information. Research limitations/implications - Community involvement is key in developing a well-accepted and culturally-relevant intervention. Originality/value - The paper usefully describes the process of developing and pilot testing educational materials for use in an intervention in which barbers would be trained as community health advisors, to educate their clients about CRC screening and informed decision making for prostate cancer screening. Keywords Cancer, African Americans, Preventative medicine, Community health services, United States of America Paper type Research paper

Introduction Colorectal cancer incidence, mortality, and screening Colorectal cancer (CRC) is ranked the third most common cancer and the third leading cause of cancer-related mortality (National Cancer Institute, 2005). There are striking incidence and mortality differences between racial/ethnic groups (National Cancer This paper was supported by Grant/Cooperative Agreement Number (No. 5U48DP00046-03) from the Centers for Disease Control and Prevention. The paper's contents are solely the . responsibility of the authors and so not necessarily represent the official views of The Centers for Disease Control and Prevention. This work was approved by the University of Alabama at Birmingham Institutional Review Board (No. X05004003). The authors would like to acknowledge the contributions of Elise McLin and Mel Johnson, who contributed to the pilot testing of the intervention matel;als.

Health Education Vol. 109 NO.3. 2009 @

pp.213-21...5 Group Publishing Limited 0965-4283 DOl 10.110&'096542&>910955557

Emerald

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Institute, 2005). In particular, African-Americans expelienced a higher incidence and death rate from CRC as compared to Whites. This may be due to cancer among A.fIican-Americans being detected at a later stage, potentially due to differences in screening rates. Early detection/treatment and removal of precancerous colorectal polyps can reduce the number of deaths from CRe (National Cancer Institute, 2007). Despite screening recommendations and effectiveness, testing rates are relatively low compared to screening for other cancers (Centers for Disease Control and Prevention, 2004). Prostate cancer incidence, mortality, and informed decision making for screening Research shows prostate cancer has a disproportionate impact on certain segments of the population. For example, African-American men are more likely to develop prostate cancer and twice as likely to die from it as other American men (American Cancer Society, 2005; National Cancer Institute, 2005). Owing to uncertainties regarding the benefits of prostate cancer early detection and treatment modalities (American Cancer Society, 2005), the National Cancer Institute encourages the public and providers to make informed decisions based on the benefits and risks of various approaches. Barbershop- and salon-based approaches to health education Realizing that conventional risk-reduction messages about cancer may not be optimal for reaching A.fIican-Americans, there is a need to assess the efficacy of using non-conventional venues as viable sources of disseminating health information in minority communities. Barbershops and beauty salons are such non-conventional venues, ideal locations for a variety of service delivery, providing access to several hundred clients per month (Linnan et al., 2002). For example, in the Black Cosmetologists Promoting Health Program pilot study, African-American beauticians were recruited to participate in an educational program teaching either breast cancer information or general health information to their clients (Sadler et al., 2000). The educational program resulted in high rates of knowledge about breast cancer early detection. Stylists in another project were trained as lay health advisors and provided breast cancer information to African-American women (Wilson et al, 2008). Another barbershop-based project targeted hypertension (Hess et al, 2007). More than 150 licensed beauticians in Rhode Island reported having a total smoking ban in their salons, and those who believed that environmental tobacco smoke harms health were 88 percent more likely to choose to work in a salon with a similar policy (Linnan et al, 2002). A study conducted by Cowart et aL (2004) set out to develop a culturally competent prostate cancer education program utilizing the barbershop setting to reach and engage African-American men. Using principles of community-based participatory research, a university-community coalition was formed, and the team provided a series of on-site educational sessions to raise prostate cancer awareness and promote healthier behaviors. Another example of a barbershop-based initiative is The Prostate Net (2007) led by prostate cancer survivor Virgil Simons. The ProstateNet and Barbers International are using the power and influence of neighborhood barbershops to encourage men to get screened for prostate cancer and be more proactive about their overall health. The barbers work with local hospitals and community leaders, encouraging men to get screened for prostate cancer. In a recent report of African-American barbershop recruitment for prostate cancer education, Hart et al. (2008) reported that the shops

were in general willing to participate in the community-based research project, all indicated they would support their clients learrung about prostate cancer, and 96 percent indicated they would consider providing clients access to handheld computers to learn about prostate cancer. These initiatives illustrate the growing interest in the barbershop as a venue for health education in AiIican-American communities. Th.e present study

This paper describes the process of developing and pilot testing educational materials for use in an intervention in which barbers would be trained as community health advisors (Fendall, 1984;Giblin, 1989;Witmer et al, 1995),to educate their clients about CRCscreening and informed decision making for prostate cancer screening (activities flow chart shovm in Figure 1). A community-based pa.J.ticipatoryapproach was used (Freire, 1970; Butterfoss et al., 1993), in which the community was involved in all phases of the project, from development of the grant application, to the intervention strategy, message development, and evaluation plan. The formative research phase of the project informed intervention development. The first phase involved the development of a Community Action Plan (CAP), which served as a roadmap for intervention development and implementation. In the next phase, we developed and pilot tested the intervention. This paper outlines the development of the CAP and the development and pilot testing of the intervention materials. In the final phase, we will implement and evaluate the intervention for impact on informed decision making and screening through use of a randomized controlled trial. All project activities were conducted in close partnership with an advisory panel of community members.

Method and results Intervention development Advisory panel. First, we established rapport with local barbers, shop patrons, and

cancer survivors, and recruited them to serve on the advisory panel (demographic characteristics shown in Table 1).We had begun this process at the time the grant application was written, where we had discussions regarding their thoughts on how best to approach prostate and eRC education in the context of the barbershop. When the project formally began, the investigative team and advisory panel began to formally participate in a series of monthly meetings. Advisory panel recommendations for intervention - prostate cancer. The advisory panel recommended that the educational materials show a graphic of the prostate gland and describe what the gland does. They recommended defining the prostate-specific antigen test and explain why it is done. Risk factors for prostate cancer such as age, family history, race, and diet were suggested, as well as a telephone number that a man could contact for additional information. They felt that the materials should be attention-getting and encourage men to get checked for prostate cancer before it is too late, as well as encouraging men to talk with their doctor about getting screened, particularly those men with a family history of the disease. Statistics specific to African-Amelican men were recommended for inclusion as well. Advisory panel recommendations for intervention - eRe. The advisory panel recommendedconveying the message to be screened if one is age 50 or older,to see one's doctorabout being screened,and to learn about one's own risk factors. Statistics specificto

Cancer communication intervention

215

--~-----------------~-----

HE 109,3

Activity

Outcome

Advisory panel convened

Partnership formed

Grant application developed

Funding for project

216

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AP/Focus groups: content development

. Core content identified

Advisory panel meetings

CAP Developed

First draft content Messages developed

development

!

.

Graphic design

Prototypes

i ~

Focus groups: pilot test graphics

· Graphic design feedback

Cognitive interviews: test content

Literacy! acceptability feedback

, ;

Figure l. Intervention development and formative research activities

developed

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:----

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Materials finalized and produced

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African-American men were recommended, as well as the notion that a test for CRC may save a man's life. The motivation of being around to see one's children grow up was cited as a reason to be screened. A firnl message about the consequences of not getting screened (e.g. death) was suggested, although the team eventually agreed to avoid a strong fear appeal based on the mixed scientific literature regarding their effectiveness. Instead, a clear and proactive message was conveyed regarding the importance of screening and early detection. Pictures of polyps and a discussion of the signs and symptoms of CRC (including that there may be no symptoms at all) were recommended. The slogan "Got Checked?" was developed, based on the popularity of the "Got Milk?" campaign. The advisory panel continued to provide feedback throughout the intervention development phase (Figure 1). They selected a project logo from a series of options provided. The panel provided significant input into how the intervention efficacy would be evaluated. In one of the meetings, the principal investigator explained several research designs (e.g. pre/post-test, randomized controlled trial, and delayed treatment controlled design) along with the strengths and limitations of each. The advisory panel agreed that they wanted a rigorous evaluation of the project, however they disliked the idea of a control group in which one group of shops received no intervention, or even a delayed treatment control group in which a group of shops had to wait for an intervention. The co-principal investigator then suggested that a "comparison group" could be used, in which the "control" shops could receive education on another health topic. The panel liked this idea, and selected hypertension and diabetes. Finally, it was decided that at the end of the six-month intervention phase, the two groups of shops would "cross over" and each would receive the other community health agent (CHA) training and health intervention. It was decided to identify existing culturally relevant diabetes and hypertension materials (e.g. print materials and posters) rather than to develop and pilot test materials, due to limitations on project resources. Focus groups - content development. Two focus groups comprised of African-American men age 45-69 served to identify core prostate and CRC content for the intervention materials (demographic characteristics shown in Table I). These men were recruited from local African-American barbershops that were not to be involved in the randomized controlled trial (to avoid contamination). Groups were held on campus at the university center. Potentially interested men were screened for eligibility by self-identification. Following a semi-structured topic guide, participants in the groups discussed their needs and preferences regarding prostate and CRC education, and structural aspects of the intervention (e.g. print materials vs video and use of media). Each member of the focus groups received a gift card of $25 value. Trained focus group moderators were used to moderate the groups. The groups were audio taped and transcribed. The transcripts were independently analyzed by the investigative team and themes and patterns were noted as recommendations for the intervention. Focus group findings - prostate cancer. The men indicated they would like more information about the symptoms, prevention through lifestyle, which screening method is best, alternative treatments to surgery or radiation, risk factors, and questions to ask the doctor. Some men indicated a stigma about prostate cancer and testing for it, and that they feel that screening takes away from their manhood: Hey look, I'm healthy and I don't think I need a doctor touching me. I don't have it. The stigma or the idea of the prostate exam, the doctor got to take his finger and put it in your rectum. As a man, you got that stigma attached and you say, ''No, I don't think I need to do that; I don't

have any pain back there; I'm not comfortable with taking that type of exam." I think it's like you're saying with the young generation, I know younger men have a real problem with this. Young Black men will have a real problem There was a reported fear of treatment side effects (e.g. erectile dysfunction), and the notion that if one is feeling healthy, they do not need to be examined for prostate cancer. There was particular discussion around the digital rectal examination, with participants indicating that it feels degrading the first time, is uncomfortable, and may even make some men have uncomfortable thoughts regarding homosexuality: Woen I was younger, I had my first one. After the men did his finger and stuff like that, I wondering now, am I gay or what. I felt funny for 3 days. I was watching my butt to see if I was walking funny [Group laughs]. However, some men cited that their comfort level increased with the number of these examinations that they had underwent: I think I was just like you the first time. My doctor had a habit of saying, "It hurts me worst than it hurts you." After awhile, I got more comfortable with it because I knew this was something I had to have done,periodically. I think the age and first time on anything, you got to get comfortable with it. When asked what the men felt that men in their community needed to know about prostate cancer, they indicated they needed to know why the doctor wants to do the digital rectal examination (e.g. what they are looking for) rather than just proceeding with the examination, what and where is the prostate and what is its function, what tests are available for prostate cancer, and what would happen if a man did not get tested. They wanted to know more about the role of family history, whether prostate cancer is curable if found early, and that things that one may think are symptoms may be caused by something else (e.g. prostatitis). The men discussed the importance of dispelling myths, where to go for testing even if one did not have health insurance, and they expressed a desire to begin talking to men about annual checkups at an early age (e.g. 18). Participants reported screening barriers such as myths, potential loss of sex drive and/or reproductive system, cost of testing particularly without health insurance, low-comfort level with the screening procedure itself, and low awareness of the need for screening. Focus group findings - eRe. The men indicated they would like to know "everything" or "anything" about CRC, reflecting a lower level of awareness than with prostate cancer. They wanted to know: What can I do to prevent it? Do I need to change my diet, exercise more? I want to know that kind of information. I want to know more about the colonoscopy.I know about it, but I would like somebody to sit down and talk to me in more detail about that exam. I know that's the test they use. How often should you have the test? When you turn 50, [am] I clean at that point? When do I need to have it again? Participants also wanted information about the role of family history. Perceived barriers to CRC screening included the notion that screening is violating, lack of knowledge of the screening tests themselves (e.g. "what's involved"), lack of symptoms, cost/lack of insurance, fear, lack of time, and the feeling that if a person had lived long enough without having the screening, perhaps they did not need to have it. Perceived myths associated with CRC included the notion that once air hits the tumor that it would spread, and some did not know the purpose of the colostomy bag.

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Focus group findings - barbershop cancer educational approach. Finally, the men were asked their thoughts on the best approach to conducting men's health education in a barbershop setting. They reported that the barbers need to be properly trained to be perceived as credible: If he's going to educate us and you're going to b-ainhim to educate us, give him some kind of cTedentialshe can hang on his wall. I mean give him some kind of credentials that he can display to say I've been through the DAB Program and I'm qualified to speak to you about colon cancer and that will add some credibility to it. It was recommended that the barbers should use visual aids and/or print materials: If you got a pamphlet and somebody is sitting down waiting to get their haircut, then they open this pamphlet and the barber looks over there and· says, hey man, read that stuff and I can tell you about it. If the barber can help you understand what's in the pamphlet, and a pamphlet along with pictures, along with the barber being able to relate what they're looking at, then it would help. Participants indicated that if the barbers were also cancer survivors, this would increase their credibility. Participants favored use of videos with African-American as opposed to White physicians, print materials, and use of incentives such as discounted haircuts. Development of the CAP The CAP served as a type ofroadmap to lead intervention and evaluation efforts. The CAP outlines the objectives and aims of the intervention, as well as the priority audience. It outlines the structure of the intervention and components, including the CRA training manuals, CRA training workshops, use of educational materials such as print materials, posters, and videos, the intervention and study design, and evaluation strategy. The CAP was developed with extensive participation from community members, including the advisory panel, and based on the formative research activities (the aforementioned focus groups - Figure 1).During this part of this phase, we accomplished several tasks. First, we conducted a content analysis of the focus group data. Transcripts were independently reviewed by several investigators and advisory panel members. Second, based on the conclusions drawn from these data, we drafted the CAP. This included a series of meetings of the advisory panel, investigators and project staff. Core content development Core content for an educational booklet on prostate cancer screening and one for CRC screening was derived from the CDC booklet, Prostate Cancer Screening: A Decision Guide for African-Americans, and the CDC screen for Life Campaign: Colm'ectal Cancer Basic Facts on Screening, and was based on the informational needs derived from the two focus groups. Content for these educational booklets was drafted based on input from the advisory panel and focus groups. Theory was also integrated into both the written content as well as the evaluation plan, based on the concepts of perceived susceptibility, perceived severity, perceived barriers to and benefits of screening, and self-efficacy, from the Health Belief Model (Rosenstock, 1960). Pilot testing the intervention Focus groups - mate1ials pilot testing. Two focus groups of African-American men age 45-69 were used to pilot test the intervention format and content (demographic

characteristics shown in Table I). The same recruitment, data collection and data analysis procedures were used as in the previous focus groups. The groups were presented with intervention prototypes (posters and print materials) and provided feedback as to the appropriateness and acceptability of the graphics and content. Focus group findings. In these groups, participants indicated their preferences from among several prostate and CRC educational booklet prototypes and several poster prototypes. A blue-color scheme was preferred to a broWl1 or white scheme. Photographs and graphics of real-looking men or men shO\vn with families were preferred. The men liked seeing a variety of pictures of different African-American men, in that several socioeconomic groups were represented. Participants preferred a line diagram of the prostate and colon to more elaborate diagrams. They preferred fonts that were easy to read, as well as a graphic of an African-American physician. Brief materials using bullet points and summaries were prefelTed to longer narratives. Revisions were made to the prototypes based on these suggestions and the next focus group was shown a revised set of prototypes. Their feedback was consistent with that of the previous group, and additionally indicating that there needed to be a connection or "flow" between the title and cover graphics for a consistent theme or branding, and to include statistics for cancer incidence and mortality for African-American men. It was suggested that on the posters, a telephone number be included so that men could call for more information. The American Cancer Society phone number was chosen because a live person can be reached at all times of the day and week, and for the rich availability of local resources. Cognitive response interviews. Cognitive response interviews were used to pilot written content of the materials to make sure that it was understandable and acceptable to members of the priority population. African-American men age 45-69 pilot tested the written content of the educational materials (demographic characteristics shown in Table I). These men were recruited from non-intervention barbershops, a local African-American fraternity chapter, and other ongoing health education projects. Potential participants were instructed to call study staff if interested. They were screened for eligibility as in the focus groups. They made one-hour appointments with research staff to read passages from the interventions and answer open-ended questions about what they read (cognitive response technique). Cognitive response procedures involve intensive one-on-one interviews in which participants may be asked to think aloud about the passages they have read, paraphrase the content, and respond to other inquiries and probes Gabine et al., 1984; Forsyth and Lessler, 1991; Sudman et al., 1996). Interviews were recorded, transcribed, and reviewed by multiple staff members (Caspar, 1997). Recommendations were then made for the revision of difficult or offensive material. Each cognitive response interview participant received a gift card of $25 value. Cognitive response interview findings. Participants overwhelmingly understood the material and did not find it to be inappropriate. For example, we tested material such as: "Small polyps are usually not cancerous. However, over time, cells in a polyp can change and become cancerous. Removing polyps early may prevent cancer from ever forming." Participant's paraphrase responses such as "That these cancer cells can be avoided. If the polyps are removed early enough it can prevent the spread of the cancer in the person's body," and "With regular screening, polyps in the colon can be removed before they become cancerous," suggested that the men had an understanding of the material. Another example of a passage, we tested was:

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Most often these [colorectal cancer] symptoms are not due to cancer. Anyone with these symptoms should see a doctor so that any problem can be diagnosed and treated as early as possible. Other health problems can cause the same symptoms. Participant's paraphrase responses such as "All the symptoms shown above, they may not mean that you have cancer and you could have other health problems that cause those things," and "You may have some of the symptoms here, but you need to see a doctor but it doesn't necessarily mean you have cancer," suggested an understanding of this passage. The only exception was where a modification had to be made included the word "folate", which most participants were not familiar with ("I don't really have a good feel for that word. It would appear to be something like a tree - it grows like a leaf, but I would think that folate would mean something else."; "I never heard the word folate. Folate means to me [... J sounds like a piece of foil [... J like something you can preserve."). Since the materials needed to be brief we elected to eliminate the mention of folate. It was more distracting to go into a detailed discussion of folate than to remain focused on CRC early detection. The reading level of the materials tested at the 6.5 grade level using Flesch-Kincaid. CHA curriculum development. In order to adequately train the CHAs, we reviewed existing CHAJpeer-health educator curriculums and manuals that have been developed and used in the past. We developed a first draft of the training manual. The manual covered topics including the project overview, overview of cancer, prostate and CRC (anatomy, risk factors, screening, symptoms, diagnosis/treatment/side effects, and questions for the doctor), informed decision making, communication, ethics and confidentiality in research, communicating messages in the barbershop, and local cancer resources. The advisory panel was asked to make recommendations, particularly focusing on the outline of the content and structural aspects of the training (e.g. when to hold the training, how long the training should last). An iterative process of editing followed, and the manual was finalized. Final intervention materials. This iterative process resulted in an intervention protocol and package of educational materials that were developed and pilot tested with extensive input from African-American men. The protocol is based on the CAP, and includes two professionally prepared CHA manuals (one prostate and CRC and one diabetes and hypertension), an educational booklet on informed decision making for prostate cancer screening, an educational booklet on CRC screening, a series of posters on each of these topics, and evaluation materials and protocols. Existing materials were sought for prostate and CRC videos, and for the diabetes and hypertension educational materials, in an effort to conserve project resources. In the next phase of the project, barbers will receive training as CHAs. They will teach their clients about these health issues, and navigate the clients through the study protocol and evaluation materials. A six-month follow-up survey will determine whether or not the interventions are effective for increasing knowledge and health behaviors.

Discussion By working closely with the community, we were able to develop and pilot test a barbershop-based educational intervention aimed at increasing CRCscreening and informed decision making for prostate cancer screening among African-American men, a group that is disproportionately impacted by these diseases. Unexpectedly, we also developed a parallel

intervention aimed at control of diabetes and hypertension, which will serve as the Cancer comparison condition. This is an example of a university-community partnership in which communication shared decision making was engaged in, in all phases of the project. In the next phase of the intervention project, we will determine whether the intervention evaluation strategies that were developed will be feasible for implementation, and if so, whether they are effective in impacting these diseases, from which African-American communities suffering. The focus groups were a valuable way of both identifying core content and pilot testing graphical presentation of the educational materials. From these groups, we -------learned what the important issues of focus should be, and how the information should be presented. The project team wanted to be sure to be respectful of the barber's time and the burden that the project would potentially place on them. A balance of project responsibilities has been achieved between the barbers, shop owners, and project staff. The advisory panel played a key role in the development of the evaluation plan. They were able to make an informed decision about what they felt that their community would tolerate, but would give the strongest possible evaluation data, which would maximize the potential for future funding for this and other related projects in their community. While there are few pub lished studies examining the use of barbershops as a venue to educate African-American men about prostate and CRCs, one study conducted by Cowart et ai. (2004) conducted a similar project using community-based participatory research principles to educate African-American men about prostate cancer. They also actively involved the community in the development of culturally appropriate health messages and the development of a prostate cancer brochure. Like the present study, these ongoing discussions proved to be invaluable to the success of the project. However, unlike Cowart et ai. (2004) who utilized trained nurses and health professionals to deliver their intervention in the barbershops, we elected to train the local barbers as CHAs to deliver the prostate and colorectal health messages in their shops. The present study is also similar to The Prostate Net (2007), in that prostate health information is presented in a barbershop setting. However, the Barbershop Men's Health Project differs because CRC (and diabetes and hypertension) information is also presented, and the barbers take a more active role as trained CHAs, having one-on-one conversations with their clients, and being responsible for administering baseline and follow-up evaluation surveys. In addition, The Prostate Net uses an interactive web-based kiosk to educate the men about prostate cancer, while the Barbershop Men's Health Project uses print materials, videos, posters, and one-on-one conversations with the CHAs. The Prostate Net also has a stronger screening component, in which the men are formally connected with prostate cancer screening through partnerships with local hospitals, where the Barbershop Men's Health Project encourages IDM and provides local screening resources.

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Limitations There are some limitations that must be recognized with regard to the approach taken in the development of this intervention. The men who participated in the intervention development phase (advisory panel, focus groups, and cognitive response interviews) may not be representative of the community's views, perspectives, and opinions. Although great care was taken to recruit a diverse group, participants who self-directed to participate in this capacity may be particularly health-focused and motivated with regard to health promotion or disease prevention. In addition, it is unknown how such a program would be received were it implemented in a different geographic region of the country.

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Future research The next phase of this project will involve evaluation of the developed intervention through use of a randomized controlled trial in which the shops are assigned to receive the prostate/CRC or hypertension/diabetes education. This community-based intervention strategy established a partnership and grassroots network that could also be applied in other areas of cancer control among underserved population groups. If found to be feasible in the implementation phase, the CRA approach could be used in barbershops targeting additional conditions or diseases that disproportionately impact the African-American community, such as obesity or stroke.

References American Cancer Society (2005), Cancer Facts and Figures for African Americans 2005-2006, American Cancer Society, Atlanta, GA. Butterfoss, FD., Goodman, RM. and Wandersman, A. (1993), "Community coalitions for prevention and health promotion", Health Education Reseanh, Vol. 8 NO.3, pp. 315-30. Caspar, RA (1997), Cognitive Laboratory Methods T/'aining Course, Health Communication Research Laboratory, Saint Louis University, St Louis, MO, March 7. Centers for Disease Control and Prevention (2004), Behavi01'Ol Risk Factors SUl1)eillance System (BRFSS): H-evaknce Data, U.S. Department of Health and Human Services, Washington, DC, available at: www.cdc.gov/brfss Cowart, L.W., Brown, B. and Biro, D.]. (2004), "Educating African American men about prostate cancer: the barbershop program", AmeYicanJournal of Health Studies, Vol. 19, pp. 205-13. Fendall, R (1984), "We expect too much from community health workers", World Health Forum, Vol. 5, pp. 300-3. Forsyth, E. and Lessler, ]. (1991), "Cognitive laboratory methods: a taxonomy", in Biemer, P.P., Groves, RM., Lyberg, L.E., Mathiowetz, N.A. and Sudman, S. (Eds), Measurement Errors in Surveys, Vol. 1, Wiley, New York, NY, pp. 393·418. Freire, P. (1970), "Pedagogia do oprimido", Rio de Janeiro, Paz e Terra, sao Paulo. Giblin, P.T. (1989), "Effective utilization and evaluation Public Health Reports, Vol. 104 NO.4, pp. 361-8.

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Hart, A. Jr, Underwood, S.M., Smith, W.R., Bowen, D.]., Rivers, BM., Jones, R.A., Parker, D. and Allen, Jc. (2008), "Recruiting African-American barbershops for prostate cancer education", Journal of the National Medical Association, Vol. 100, pp. 1012-20. Hess, P., Reingold,]., Jones,]., Fellman, M., Knowles, P., Ravenell, J, Kim, S., Raju,]., Ruger, E., Clark, S., Okoro, C., Ogunji, 0., Knowles, P., Leonard, D., Wilson, R., Haley, R, Ferdinand, K., Freeman, A. and Victor, R (2007), "Barbershops as hypertension detection, referral, and follow-up centers for black men", Hypertension, Vol. 49, pp. 1040-6. Jabine, T., Straf, M., Tanur,J and Tourangeau, R (1984), Cognitive Aspects of Survey Methodology: Building a Bridge Between Disciplines, National Academy Press, Washington, DC. Linnan, L.A., Emmons, K.M. and Abrams, D.E. (2002), "Beauty and the beast: results of the Rhode Island smokefree shop initiative", American Journal of Public Health, Vol. 92 NO.1, pp.27-8. National Cancer Institute (2005), SEER Report, available at: http://seer.cancer.gov National Cancer Institute (2007), Colorectal Cancer Screening: Questions and Answers, available at: www.cancer.gov/cancertopics/factsheetlDetection/colorectal-screening (The) Prostate Net (2007), available at: www.prostate-online.org/

Rosenstock. LM. (1960), "What research in motivation Joumal of Public Health, Vol. 50, pp. 295-302.

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Sadler, GR, Thomas, A.G., Gebrekristos, B., Dhanjal, S.K. and Mugo, J (2000), "Black cosmetologists promoting health program pilot study outcomes", Journal of Cancer Education Sp17ng, Vol. 15 NO.1, pp. 33-7. Sudman, S., Bradburn, N. and Schwartz, N. (1996), Thinking about Answers: The Application of Cognitive Processes to Survey Methodology, Jossey-Bass, San Francisco, CA. Wilson, T., Fraser-White, M., Feldman, J, Hamel, P., Wl;ght, S., King, G., Coll, B., Banks, S., Davis-King, D., Price, M. and Browne, R. (2008), "Hair salon stylists as breast cancer prevention lay health advisors for African American and Afro-Caribbean women",journal of Health Care for the Poor and Undeserved, Vol. 19, pp. 216-26. Witmer, A., Seifer, S.D., Finocchio, L., Leslie, J and O'Neil, E.H. (1995), "Community health workers: integral members of the health care work force", American Journal of Public Health, Vol. 85 NO.8, pp. 1055-8. Authors and affiliations Cheryl L. Holt, Department of Public and Community Health, School of Public Health, University of Maryland, College Park, Maryland, USA. Theresa A. Wynn and Ivey Lewis, Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA. Mark S. Litaker, School of Diagnostic Sciences, University of Alabama at Birmingham, Birmingham, Alabama, USA. Sanford Jeames, Donahue Institute, University of Massachusetts, Hadley, Massachusetts, USA. Francine Huckaby, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA. Leonardo Stroud, Epidemiology and Applied Research Branch, Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA. Penny L. Southward, Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA. Virgil Simons, The Prostate Net, Hackensack, New Jersey, USA. Crystal Lee, Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA. Louis Ross and Theodies Mitchell, Centers for Disease Control and Prevention, Atlanta, Georgia, USA. Corresponding author Cheryl L. Holt can be contacted at: [email protected]

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