Bridging the Gap: Engaging Black Men in Lung Cancer Research Through Barbershop Collaboration

Abstract

Health disparities persist among Black men, notably in the context of lung cancer and stress-related health outcomes. This study explores these disparities through a community-based participatory research (CBPR) approach, citizen science, and social network theory, leveraging the expertise and trust of Black barbers as community leaders. The purpose is to understand the nuanced connections between stress and lung cancer in this demographic. Engaging 161 Black men across four Chicago neighborhoods, the study successfully collected hair samples and survey data, emphasizing the importance of culturally sensitive recruitment strategies. Findings highlight the effectiveness of the collaboration, showcasing the role of barbershops as community hubs for research. The study concludes by advocating for sustained partnerships with community leaders, emphasizing transparency in research communication, and promoting culturally grounded approaches to address health disparities and enhance research participation among underrepresented populations.

Introduction

Health disparities in the United States have been the focus of increasing attention in the 21st century. Despite efforts to address these disparities, one alarming fact persists: Black men continue to experience shorter average life spans and poorer overall health compared with most other racial and ethnic groups of men (Bond & Herman, 2016). The life expectancy for Black men significantly lags behind that of White and Latino men, with figures standing at 68 years compared with 75 and 75 years, respectively (Arias & Xu, 2022). While Black men share many common causes of death with other male populations, there are distinct disparities at the crossroads of race, ethnicity, and age (Gilbert et al., 2016). One notable health disparity is lung cancer. Black Americans continue to face a higher risk of morbidity and mortality associated with lung cancer (Li et al., 2018; Olaku & Taylor, 2017; Sin, 2017). On a national level, the incidence rate of lung cancer is higher among Black Americans (59.0/100,000) compared with White Americans (52.1/100,000) (Centers for Disease Control and Prevention, 2018). In the city of Chicago, which is characterized by significant racial disparities in health and segregation, the lung cancer incidence and mortality gaps between Black and White Chicagoans are even larger than the national disparities (Centers for Disease Control and Prevention, 2018). The lung cancer incidence between Black Chicagoans and White Chicagoans is 20% larger than the national rate ratio (Illinois Department of Public Health, 2016); and the mortality rate gap between Black Chicagoans and White Chicagoans (60.5 vs. 39.7) is even greater compared with the national level (40.0 and 39.2) difference (Centers for Disease Control and Prevention, 2018; Illinois Department of Public Health, 2016; Smith et al., 2019). Health conditions such as lung cancer tend to be more severe, less controlled, and more likely to lead to premature death among Black men compared with other subgroups (Gilbert et al., 2016). Lung cancer continues to pose a significant health burden on Black men, reflecting broader trends in cancer disparities Engaging Black men in awareness of existing disparity and education on prevention and early detection is essential to addressing the health challenges (Nesbitt & Palomarez, 2016). By raising awareness about social determinants and systemic barriers that contribute to elevated cancer risk among Black men, we can foster a more informed and empowered community (Coughlin et al., 2014).

Furthermore, efforts in cancer prevention and intervention should be tailored specifically to the unique circumstances and stressors experienced by Black men. Equipping Black men with the knowledge and resources for lifestyle modifications and cancer screening is needed to navigate and overcome systemic obstacles (Coughlin et al., 2014; Nesbitt & Palomarez, 2016; Okoro et al., 2020). Culturally sensitive and community-centered interventions have the potential to bridge the existing gaps in knowledge, access, and utilization, ultimately contributing to the reduction in the health disparities faced by Black men (Coughlin et al., 2014; Nesbitt & Palomarez, 2016; Okoro et al., 2020).

Previous studies have explored physical and mental health differences among various subgroups of men concerning race and age (Affleck et al., 2018; Bränström et al., 2016; Meyer et al., 2014; Williams & Cooper, 2019). However, there has been a noticeable gap in understanding how these socially defined characteristics interact with biological mechanisms to influence Black men’s health. A more in-depth examination of Black men is essential to comprehend the patterns of health and health disparities.

It is well-recognized that health disparities are a consequence of differential exposure to stressors rooted in societal inequities and the limited coping resources available to marginalized social groups. Stress is a condition characterized by the perception or actual disruption of our body’s internal balance (homeostasis), and it triggers a range of adaptive physiological and behavioral responses. Stressors, which can be either physical or emotional, initiate the stress response. This response involves the release of glucocorticoids via the hypothalamic–pituitary–adrenal axis and epinephrine/norepinephrine through the activation of the sympathetic nervous system. These hormonal and neurotransmitter changes lead to various physiological and metabolic alterations, impacting processes like inflammation regulation and immune system suppression, especially among marginalized communities (Affleck et al., 2018; Simons et al., 2021; Taggart et al., 2023). Consequently, these marginalized groups tend to develop age-related health conditions at an earlier stage of life, contributing to health disparities that intensify with age (Renzaho et al., 2014; Simons et al., 2021; Taggart et al., 2023; Williams & Cooper, 2019). The exposure to stressors is intricately patterned based on the intersections of socially defined and meaningful characteristics, such as race and sex. Racial groups, while heterogeneous, collectively experience varying degrees of interpersonal and institutional racism and social marginalization, leading to differences in shared experiences of discrimination and privilege (Elias & Paradies, 2021). The intertwining of race and sex further shapes the types and intensity of stressors faced by men, affecting their psychological and biobehavioral responses and, subsequently, their health outcomes (Vega Ocasio et al., 2021; Williams, 2018). Black men, in particular, confront stressors specific to the combined influence of their race and sex. These stressors often include heightened discrimination, particularly harmful gendered racism, such as stereotypes portraying Black men as dangerous (Smith et al., 2011; Zamani-Gallaher & Polite, 2012). Psychosocial stressors linked to poor health outcomes for Black men encompass negative stereotypes, interpersonal and structural discrimination, economic disparities, residential segregation, inadequate health care access, involvement with the criminal justice system, and barriers to fulfilling valued masculine roles (Chae et al., 2014; Gilbert et al., 2016; Griffith et al., 2013). Emerging research also suggests that social factors, such as chronic exposure to high crime/violence and other disadvantages, may also contribute to the elevated risk of stress in Black men (Bollig-Fischer et al., 2015; de Groot et al., 2018; Gomez et al., 2015). Chronic exposure to violence has been shown to exacerbate and perpetuate systemic inflammatory responses (Bollig-Fischer et al., 2015; de Groot et al., 2018; Gomez et al., 2015).

The substantial stressors faced by many Black men may accelerate biological aging and physiological deterioration, resulting in the disproportionate burden of morbidity and early mortality documented among this demographic. An approach that considers the combined influences of race and male sex may offer insights into the specific mechanisms contributing to health disparities that distinguish Black men from other racial and ethnic groups of men.

Although direct studies focusing specifically on the connection between stress and lung cancer may be limited, a robust body of existing research has successfully established a pervasive link between stress and various types of cancer (Falcinelli et al., 2021). A meta-analytic study presented a comprehensive overview, revealing that stress-related psychosocial factors contribute significantly to higher cancer incidence in initially healthy populations (Chida et al., 2008). This broader understanding positions stress as a potential contributor to cancer development and progression.

Expanding on this foundation, Ma and Kroemer’s (2023) exploration of the cancer-immune dialogue in the context of stress emphasizes the intricate ways in which stress influences the evolution, dissemination, and therapeutic outcomes of neoplasia. While their focus extends beyond lung cancer, the interconnected nature of stress responses and cancer dynamics suggests a relevance that transcends specific cancer types. Similarly, Bernabé et al.’s (2011) study delves into the effects of stress-related hormones on oral squamous cell carcinoma cells, underscoring the potential impact of stress on cancer cell behavior. Tian et al.’s (2019) research sheds light on the correlation between glucocorticoid receptor activation and proliferation in metastatic colon cancer, reinforcing the notion that stress-related molecular mechanisms can influence cancer outcomes.

Against this backdrop, our study aims to take a focused and nuanced approach, exploring the unique implications of stress in the context of lung cancer among Black men. Leveraging insights from previous studies that elucidate stress-cancer associations, we endeavor to uncover specific factors that may influence lung cancer outcomes within this demographic, contributing to a more targeted and comprehensive understanding of stress and its role in lung cancer among Black men.

As a potential indicator of the development of lung cancer and early mortality, hair cortisol can be a valuable tool for exploring pathways contributing to the unique health patterns among Black men (Allen et al., 2019; Blodgett et al., 2017; Iob & Steptoe, 2019; Juster et al., 2010). Growing evidence suggests that hair cortisol levels are responsive to exposure to psychosocial and environmental stressors (Karlén et al., 2015; Lynch et al., 2022; Staufenbiel et al., 2013; Wosu et al., 2013). When the biological systems involved in the stress response become overburdened due to prolonged exposure to toxic stressors, the physiological stress response becomes dysregulated. Under these conditions, the hypothalamic–pituitary–adrenal (HPA) axis fails to generate robust surges of cortisol and other stress hormones when necessary, or as part of naturally occurring daily fluctuations, leading to various premature health conditions (Karlén et al., 2015; Lynch et al., 2022; Staufenbiel et al., 2013; Wosu et al., 2013). While hair cortisol may be linked to various physical and mental health issues in diverse samples, few studies have specifically examined these findings in Black men (Kalliokoski et al., 2019; Staufenbiel et al., 2013).

Understanding the biological mechanisms by which social stress impacts Black men is challenging, particularly due to the necessity for unique and effective recruitment methods. Researchers often encounter barriers when recruiting racial/ethnic minorities and underrepresented groups into research (George et al., 2014). Barriers include limited awareness of existing research projects, lack of culturally appropriate information, and the complex nature of research investigation, which can make it difficult for individuals to see the connection between research objectives and disease prevention or treatment. In addition, time constraints, loss of income, and transportation issues can limit research participation (Hughes et al., 2017; Rivers et al., 2013).

For Black Americans, mistrust in research and the medical system can contribute to reluctance to participate (George et al., 2014; Hughes et al., 2017; Rivers et al., 2013). Historical events like the Tuskegee Study have left a legacy of mistrust among Black Americans, making them hesitant to participate in research (Hughes et al., 2017). Several barriers to research participation are tied to establishing rapport and maintaining engagement, making it essential to build trust with Black men and ensure they understand the research’s goals (Hamel et al., 2016; Nazha et al., 2019).

Scholars reported that Black Americans are more likely to participate in research if they have safety assurance in the project, trust in the researcher, and the reputation of the research institution (George et al., 2014). Therefore, the challenge is not that Black men are hard to recruit, rather researchers need to improve their recruitment approaches by building trust with Black men and ensuring they understand the project’s aims. There are additional barriers in recruiting Black men due to challenges in collecting hair samples from this population (Cooper et al., 2012). Cultural beliefs and practices surrounding hair are particularly prevalent among various minority groups (Sherrow, 2023). For example, uncut hair is seen as a religious requirement or symbol of spirituality in many minority communities and dreadlocks a cultural significance in various communities, including Rastafarians and African cultures represent spirituality, identity, and connection to African roots, and a symbol of strength in Native American culture (Sherrow, 2023). In the case of Black Americans, scalp hair holds deep personal significance and plays a vital role in their body image (Ford et al., 2016). Handling the hair of Black Americans requires specific techniques distinct from those used for other racial/ethnic groups (Wright et al., 2018).

Black Americans can have a diverse range of hair types, including straight, thin, curly, kinky, coarse, or a combination of these textures (Wright et al., 2018). Collecting and securing appropriate hair samples for processing may necessitate employing different techniques tailored to the specific characteristics of each hair type. The process of gathering hair samples from Black Americans for measuring hair cortisol takes a very careful and technical approach. In addition, collecting biological samples from Black men presents challenges due to lack of awareness about tissue research, mistrust of research practices, concerns about privacy, and need for compensation to encourage participation (Drake et al., 2017; Spence & Oltmanns, 2011). In a systematic review, researchers reported that participation in research including biological samples wat only 8% for Black Americans compared with 75% for White Americans (Allison et al., 2022). This emphasizes the need to improve recruitment strategies to better understand the biological mechanism leading to health disparities in Black men.

Over the years, scholars have aimed to address challenges to the engagement of Black men in research (Matthews et al., 2022; Watson et al., 2019). Collaboration with community leaders, specifically barbers, to obtain guidance and liaise with potential participants (Watson et al., 2020). Utilizing local barbershops has to be an effective approach to recruiting Black men in cancer research (Watson et al., 2019). Employing strategies to prioritize cultural awareness and foster meaningful relationships between the research team and the community is an important element for successful research (Barrett et al., 2017). This involves understanding the different cultural practices, beliefs, values, and norms of the research participants. Evidence that partnering with local barbershops helps overcome barriers including mistrust (George et al., 2014). Barbershops are seen as a cultural hub-spot and are known to be gathering places where Black men can socialize comfortably (Sapong, 2014). Since 2010, researchers have been using barbershops as a place to share important health information about various health topics (Releford et al., 2010). Barbershops also tend to have a high volume of men that visit every day, making it an opportune location to reach a large number of the target population.

Building on the existing research findings, our research team established and expanded relationships with local barbershops in different Chicago communities. Through these relationships with barbers, our research team was able to complete survey questions on demographic characteristics, perceived stress and collected hair samples to measure cortisol levels. Our recruitment efforts were based on a triad theoretical framework that includes Community-Based Participatory Research (CBPR), Citizen Scientists (CS), and Social Network Theory (SNT), which was introduced to improve recruitment of under-engaged populations in research (Watson et al., 2019). Figure 1 illustrates components of our recruitment approach based on the triad theoretical framework that guided our collaboration with Black barbers to engage Black men in our research concerning the link between social stress and lung cancer.

Figure 1.

Research Recruitment Approach Through Local Barbershops.

The CBPR approach, involving community members in the research process, aimed to address power imbalances and increase participation rates. A Community Advisory Board (CAB), comprising four collaborating barbers, played a key role in guiding the research (Rhodes et al., 2017). The CS component involved training community members for research activities and outreach, contributing to meaningful engagement of Black men in our project. While not formally trained as citizen scientists, two barbers had prior CS training (Watson et al., 2020). SNT focused on leveraging individuals’ interpersonal relationships, with two barbers recruited through social networks (Nimmon et al., 2019). We utilized the barbers’ clientele as part of a multilayered recruitment strategy to enhance our approach.

Method

Setting

This study was conducted as part of a larger research project funded by the National Institute of Minority Health and Health Disparities. One of the aims of this study was to explore the relationship between exposure to neighborhood crime and stress response. An in-person survey was conducted, and hair samples were collected from Black men at four neighborhood barbershops in Chicago. The selection of the four barbershops was based on neighborhood violence, in this case, homicide rates, within Chicago’s Black communities. The barbershops were located in Englewood, South Shore, Austin, and North Lawndale, all of which are predominantly Black communities with more than 80% of residents being Black. The homicide rates among these four communities vary from 59 per 100,000 in South Shore, 67 per 100,000 residents in Austin, 86 per 100,000 in Englewood, and 82 per 100,000 in North Lawndale (Chicago Health Atlas, 2021). Considering that the overall Chicago homicide rate was 21 per 100,000, these communities were disproportionately affected by neighborhood violence (Chicago Health Atlas, 2021).

Eligibility and Recruitment

The study protocol was approved by the University of Illinois at Chicago Institutional Review Board (2022-0301). All participants provided written informed consent before enrollment in the study. Inclusion criteria were self-identified as Black men, aged between 45 and 80 years, being a current or former smoker, and residing in the areas where the barbershops were located. Exclusion criteria included individuals with a previous lung cancer diagnosis and those who were using steroids.

The research team met with the barbers to review the study protocol and seek their expert opinions on the most effective method of engaging with their clients. The barbers suggested that they first introduce the study to their clients, allowing clients to consider participation. This approach was deemed more comfortable for clients compared with being approached by an unknown research individual. The barbers also recommended setting up a recruitment table in their barbershops, representing the University of Illinois Chicago, similar to a health fair setup, with informative materials on how to improve their health.

Multiple recruitment approaches were implemented, including the distribution of recruitment flyers within the barbershops and to their clients. The flyers included a brief study description, eligibility criteria, and contact information for the research team. The research team also scheduled specific days to visit the barbershops and actively recruit participants by approaching clients waiting for their haircuts. In addition, the barbers utilized their social connections to engage in word-of-mouth promotion of the research project to their clients.

Interested individuals were able to contact the research team or approach the team while at the barbershop. Potential participants then met with the research team before their haircut appointment. The research team, consisting of an interviewer and a project manager, conducted a screening process to determine eligibility using a checklist of inclusion criteria. The screening process took approximately 5 min and was conducted during the barbershop visit. Participants who met the criteria were enrolled in the study.

The research team thoroughly reviewed the consent document with the participants, emphasizing the voluntary nature of participation and the ability to withdraw at any time. Participants were provided with information regarding the study’s purpose, the activities they would be asked to undertake (hair sample collection and survey questionnaire), and details regarding participant reimbursement. Approximately 40 participants were recruited from each barbershop, totaling 161 participants. Participants were compensated for their time contributing to the study.

Data Collection

Participants were provided a questionnaire to further understand their neighborhood stress. Participants took 40 min to complete the survey and completed it while they awaited their haircut. Once they completed their survey, they received their haircut which took another 40 min. Hair samples were collected following the method previously reported by Wright et al. (2018). The study staff worked in collaboration with the barbers to ensure optimal hair sample collection. The barbers used cleaned electric clippers to collect the hair samples. The targeted area for sample collection was the posterior vertex, located at the scalp level on any portion of the head. This specific area was chosen to ensure consistency and standardized collection across all participants.

Because 1 cm of hair represents cortisol deposition over 1 month before the haircut appointment, as scalp hair grows at an average rate of 1 cm per month (Cooper et al., 2012); therefore, an adequate amount of hair for the study was about 1 cm in length. Stress Bioanalytics LLC, the lab analyzing the hair samples requested we collect 2.5 to 20 mg of hair. This allowed them to accurately measure about 1 month of hair cortisol from participants. Given that most of the participants had short hair, the barbers carefully cut an approximate amount of hair required, aiming to collect a minimum of 2.5 mg of hair from the scalp level. Following the hair sample collection, the barbers proceeded to complete the clients’ haircuts as requested by the clients.

Results

We recruited and completed surveys and hair sample collection with 161 Black men from four barbershops within 3 months from June 2022 to August 2022. This successful data collection was possible through consistent collaboration with four barbershops in four predominantly Black communities in Chicago. Our research team met with the barbers multiple times before recruiting to develop strong partnerships and refine recruitment protocols based on the feedback we received from the barbers. The research team spent time in the barbershop to build rapport with the barbers and potential future participants.

In the 3 months, the research team was recruiting at the barbershops only one potential participant denied participating given the limited time they had. Each participant completed a questionnaire regarding socio-environmental factors and provided a hair sample. The research staff and barbers ensured that the information they were providing would be used to advance lung cancer research and improve trust with the research staff, and the research team would do their best to secure privacy and confidentiality. Participants expressed no concerns with providing a hair sample given that the barbers knew how to make sure their clients received their haircut immediately after the hair sampling. Participants stated that they trusted their barbers. The hair sampling response rate among those who consented to the study was, in fact, 100%. The median amount of hair collected was 22 mg. Four samples were in the range of 5 to 10 mg, and all other samples were above 10 mg. All collected hair samples met the weight recommendation range between 2.5 and 20 mg. Hair samples were sent to the collaborating laboratory, Stress Bioanalytics LLC where hair cortisol was successfully assessed in 100% samples with a sufficient amount of hair required for the analysis.

Discussion

In this study, we presented effective strategies for engaging Black men as both research partners and participants. The success of hair sample collection was facilitated by the established trust and relationships between the research team, barbers, and their patrons. Our recruitment approach incorporated three key components: community engagement, citizen science, and social networks. First, collaborating with barbers was a way for the research team to directly engage with community partners in the research process. Barbers were also on the community advisory board to provide valuable feedback on engaging underrepresented populations throughout the research process. Second, we collaborated with two barbers who had previously been trained as citizen scientists, which meant that barbers had extensive knowledge and experience in research recruitment approaches and data collection. Third, the research team was able to leverage barbers’ social networks to connect with many Black men who were often under-engaged with research and clinical trials (Harley et al., 2020). This approach allowed the research team to maximize the engagement of Black men who are often under-represented in cancer research.

The professional expertise of Black barbers in haircutting, coupled with their leadership roles within their communities, facilitated the relationship between researchers and participants. By collaborating with the barbers, we collected hair samples in a familiar and convenient location, addressing barriers related to time and transportation. Participants expressed confidence in providing the hair sample, as they trusted the barbers’ expertise. The barbershop setting served as an effective venue for sample collection while ensuring participant satisfaction with their haircuts.

Previous studies have highlighted the limited availability of investigators trained in collecting hair samples from Black Americans (Wright et al., 2018). In our approach, we relied on Black barbers with skills to collect hair samples and strong trusted relationships with Black men. This recruitment approach can be extrapolated to increase the representation of other under-engaged populations in research. Collaborating with barbers addresses barriers such as mistrust commonly encountered when engaging under-engaged individuals. This project built upon our research team’s previous success in developing relationships with Black leaders and utilizing the citizen scientist approach to recruiting Black men, which ensured a culturally appropriate approach to engaging underrepresented populations.

The barbers who collaborated on this project suggested other future research projects that involve barbers in all stages, including the development phase of grant proposals. They emphasized that researchers should seek their input and ideas, as they often encounter research plans that neglect their perspectives. Inclusiveness can be ensured by inviting barbers early in the grant proposal development process.

Although our recruitment strategy was highly successful, we observed participants’ hesitancy due to the traditional use of hair samples for substance use measurement. Participants expressed several concerns regarding the research study, including inquiries about handling their hair samples, the confidentiality of their personal information, and the potential for survey responses to be linked back to their identities. To assuage participant concerns, explicit assurances were provided that the research project would maintain strict confidentiality and anonymity, ensuring that personal information would not be linked back to individual identities. It was emphasized that the study would solely analyze hair cortisol levels as an indicator of stress response, without divulging any identifying details. The establishment of trust between the research team and participants was facilitated by the long-standing relationship cultivated with the barbers, who acted as trusted intermediaries. The endorsement and testimonies from the barbers played a pivotal role in fostering participant comfort and willingness to engage in the research study. Communicating the purpose of collecting hair samples and assurance that samples will be promptly destroyed with no further use is critical to be able to build and maintain trust with participants.

Several limitations should be considered when interpreting the results of this study. First, the sample size, although successfully recruited, is relatively small, which could introduce self-selection bias. Participants who voluntarily enrolled might possess unique characteristics or health behaviors that distinguish them from those who declined to participate. The focus on specific neighborhoods in Chicago might not be fully generalizable to areas with distinct demographic compositions or varying crime rates, underscoring the importance of caution when extending these findings beyond the studied context. Finally, while the successful collection of hair samples was aided by the expertise of Black barbers, the feasibility of such collection may vary in settings lacking pre-established relationships and technical support.

Conclusion

Our study highlights effective strategies for engaging Black men as research partners and participants, with the collaboration of barbers serving as a crucial element. This approach offers a culturally appropriate recruitment method to engage underrepresented populations. By involving barbers in the research process, researchers can benefit from their unique perspectives and enhance inclusiveness. Communication and transparency regarding the use of hair samples are essential to mitigate concerns and foster trust among potential participants. Researchers should continue to explore culturally appropriate recruitment strategies to increase the representation in research participation of those who are often excluded from clinical trials, interventions, and other research and yet disproportionately affected by poor health outcomes of cancer.

The effects of various stressors on immune response among Black men may be a significant driver of racial disparities. Through our collaboration with Black barbers, we have recognized future directions for improving the health of Black men. The barbers in this study have expressed interest in continuing partnerships and have offered their barbershops as locations to host future research projects that focus on an array of topics their community members may be interested in. Through this collaboration, we have also recognized that barbers continue to be key partners for research, as such, barbers and other community partners need to be involved in all stages of the research process as equitable partners from idea generation, to study implementation to dissemination of findings.