From haircuts to high blood pressure management

On a blustery fall afternoon in 2021, two pharmacists from UCSF walked into Chicago 2 Barbershop, just off Divisadero Street in the Western Addition neighborhood of San Francisco. While hair trimmers hummed and soul music spilled from wall-mounted speakers, they set up a blood pressure monitor on a small table in a back room and returned to chat with the barbers.

“We’ve got some vaccines today,” Crystal Zhou, PharmD, mentioned to a barber who was wearing a white smock bearing a logo that read “Cut Hypertension.”

“COVID vaccines?” exclaimed a nearby customer who was waiting for his haircut. “Maybe I’ll get mine, then!”

Zhou, a faculty member in the UCSF School of Pharmacy’s Department of Clinical Pharmacy, was excited to finally be back at Chicago 2. The COVID-19 pandemic had delayed her plans to routinely provide advice on hypertension (high blood pressure) in this community setting.

These plans dovetailed with the barbershop’s years-long collaboration with the Cut Hypertension Program (CHP), which trains barbers in Black communities to become health coaches to educate their clients about hypertension. Zhou serves as the lead pharmacist for the program.

For more info about the Cut Hypertension Program, please contact Crystal Zhou, PharmD (lead pharmacist); Melvin Faulk (program coordinator); or Tem Woldeyesus, MD (program director) at [email protected]. Patients or providers may submit referrals to the Cut Hypertension Program’s pilot study.

Zhou’s partnership with the CHP and Chicago 2’s CHP-trained barbers promised to connect patients more directly with the services needed to manage hypertension, including monitoring their blood pressure over time, conveying that information to their physicians, and adjusting medications if needed. The independent program is hosted by the Roots Community Health Center and sponsored by Health Net, UCSF, and Stanford University.

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Lead barber Kenneth El-Amin stands in front of Chicago 2 Barbershop.

“The barbershop has always played a critical role, bringing people together in a comfortable space. We really have a pulse on the community,” said barber Kenneth El-Amin, who was certified by the CHP to coach his clients on hypertension. “At the end of the day, we want to make sure that we’re able to be of service to our community, and that’s what we’re continuing to do, spreading the knowledge of health and how to stay healthy.”

Over a year into the pandemic, Zhou could now give the CHP-trained barbers support, advise patients directly about their hypertension medications, and even provide COVID vaccinations. She also had the help of Sarah Chong, PharmD ’21, a resident in UCSF’s PGY1 pharmacy residency program.

“I think it’s a good idea for medical professionals to go where the people are,” said Myles Dixon, a retired 65-year-old who received his COVID booster shot and had his blood pressure measured at the barbershop after receiving his first haircut and beard trim since the beginning of the pandemic. “The population that goes to the barbershop, it’s a high-risk population, whether for COVID or hypertension. To do good outreach, there’s no better place to go than barbershops.”

Pharmacists outside the pharmacy

Zhou and Chong’s presence at Chicago 2, outside of a traditional, brick-and-mortar pharmacy, is no anomaly among UCSF pharmacists. In the 1960s, UCSF pharmacists pioneered the provision of pharmacy services on the 9th floor of UCSF Medical Center, working directly with doctors, nurses, and staff to ensure the safe and effective use of medications in the hospital.

The pair are also following in the footsteps of a 2018 study that showed that partnerships between pharmacists and barbershops could reduce high blood pressure in Black men, more so than with health coaching from barbers alone. Combined with the training that four of Chicago 2’s barbers had received from the CHP, there was ample opportunity to improve lives.

“We were familiar with UCSF due to the affiliation of the [cut hypertension] program’s founder, Kenji Taylor,” said El-Amin. “Now we have this beautiful relationship with the doctors and physicians and hospitals, and we're able to do some of the things that we're doing today, like [giving Crystal] the space to give vaccines.”

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Zhou, center, and Chong, right, chat with barber Rickey Hogan after taking his blood pressure reading.

The idea for providing the vaccines at the barbershop itself was El-Amin’s, according to Zhou. It was just one example of the barbers taking it upon themselves to expand how the barbershop could benefit the community—a necessity, given the historical importance of barbershops to the Black community, as well as the Black community’s mistrust of a health care system that is too often discriminatory.

By partnering with barbers like El-Amin, Zhou and the CHP were hoping to finally break down longstanding barriers to quality health care, particularly among Black men.

“When we’re at the barbershop, the barbers are more empowered to bring up health issues with their clients,” said Zhou. “Sometimes the clients will say, ‘I've been thinking about getting vaccinated and I’m on the fence,’ or ‘I’ve had trouble making the appointments,’ and the barbers can direct those people to us for more information and even same-day vaccination.”

Early in the fall, when COVID booster shots were limited to immunocompromised people, Zhou and Chong could administer only a few vaccines each week. Once the boosters were authorized for all adults, the pace picked up, and news of the vaccines at Chicago 2 began to spread via word of mouth, according to Chong.

Zhou and Chong now see up to a dozen patients during each Friday afternoon visit to Chicago 2, administering COVID vaccines and measuring blood pressure. The interactions have opened up the chance to chat further about hypertension and health more broadly—the original purpose that the pharmacists had had in mind.

“People really trust their barbers,” said Zhou. “That trust makes them more comfortable to talk about their health in the barbershop, the first step in connecting them to more health care through us, if they need it.”

Building a lasting collaboration between barbers and pharmacists

Zhou and the CHP team are expanding their operations and monitoring the impact of their work. Do people want to receive health care after having their hair cut? Will they return? Are they more likely to go to clinics or hospitals on the advice of the pharmacists?

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Zhou, right, and CHP-trained barber Jesus Cesa chat during a break between their respective blood pressure reading and haircut appointments.

Early on, Zhou saw that few of Chicago 2’s clients had high blood pressure, perhaps reflecting their relatively young age. To find the patients who will benefit most from additional health care, the CHP is building relationships with a handful of East Bay barbershops, some which serve an older clientele. So far, CHP has recruited four patients with hypertension to participate in a pilot study that will track the impact of the program on those patients’ blood pressure.

For Chong, the experience at the barbershop is proving to be formative. She graduated from the School of Pharmacy’s doctor of pharmacy (PharmD) degree program in spring 2021 and obtained her pharmacy license a few months before first stepping into the barbershop. She also recently earned the 2022 Incentive Grant from the American Pharmacists Association (APhA) Foundation for her research on perceptions of pharmacy care occurring in barbershops.

Chong is the first of what Zhou hopes will be many pharmacists who dedicate a few hours per week providing care at barbershops. In particular, Zhou wants to make the collaboration between pharmacists and barbers financially sustainable.

“Eventually we want pharmacists to get reimbursed for their services through insurers, through payers,” said Zhou. “Maybe even the barbers will get a stipend through the insurance companies for being health coaches in the community.”

Gathering evidence of the effectiveness of the barbershop work will be key to obtaining this financial support, according to Zhou. If insurers can easily see that their customers maintain better health thanks to pharmacy care offered at a barbershop, they’ll want to compensate everyone—perhaps even the customers themselves.

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Zhou, right, places a small bandage on Jabari Thibeaux, a CHP-trained barber, after administering a COVID vaccine dose.

“For some patients who do have a hard time managing their blood pressure or getting to see their doctor, we also want to provide an incentive for them. The CHP can offer free haircuts, with money going back to the barbers,” said Chong. “These incentives can help patients get more comfortable with us and with managing their blood pressure at the clinic.”

Zhou and the CHP are also designing the next round of trainings for barbers, which will focus on conversational strategies that they can use to break the ice with their clients around topics like hypertension.

Those first interactions with clients, while they sit in the barbershop chairs, are critical to making the blood pressure readings and vaccines less intimidating, and Chong and Zhou are grateful to have the teamwork of the barbers in improving the health of the community.

“The barbershop is the last vestige of the African American community in San Francisco,” said barbershop client Dixon. “Going to this barbershop reminded me of my old neighborhood. I’ve lived in the neighborhood for 40 years and I’ve seen it change a lot. So I appreciate being able to go here and also get the care I need.”

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Myles Dixon receives a beard trim at Chicago 2 Barbershop. Dixon would go on to receive a blood pressure reading and COVID vaccination from Zhou and Chong later that afternoon.

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Dixon looks over his new haircut and beard trim in a mirror.