Vibhav Nandagiri
One organization in eastern North Carolina is taking an approach that empowers trusted voices in the community as part of an ongoing effort to reach people in non-traditional settings with important health information.
The Shackle Free Community Outreach Agency trains barbers and cosmetologists to share important information about vaccines and chronic disease prevention and treatment, as well as information about accessing food, housing and other resources.
The program, known as Shackle Free Buzz, or “The Buzz,” serves five counties: Duplin, Jones, Onslow, Pender and Sampson.
For Chiquitta Lesesne, the organization's founder and executive director, working with barbers and hairdressers to promote wellness made perfect sense.
“People are more likely to visit them than to see a doctor,” says Lesen, “and what we've found is that in many cases, people communicate their health status to a trusted communicator, like their barber.”
Over the past few years, Shackle Free has focused on building a strong community health workforce in eastern North Carolina and reaching out to rural communities of color where barriers to accessing health care persist, Resen said. In 2021, the organization partnered with the Duke Cancer Institute Office of Health Equity to provide training on how to distribute information about cancer, diabetes, hypertension and other chronic diseases. Through the session, participants were certified as community health ambassadors. Of the 101 Shackle Free community advocates who attended the four-hour training session, 41 were barbers and cosmetologists, Resen said.
“This is the largest organization we've ever trained,” said Angelo Moore, former director of the Duke University office that organized and oversaw the training. In June, Moore was named executive director of the Center for Comprehensive Health Disparities and Equity Research at North Carolina A&T State University.
Once trained, barbers and hairdressers return to their communities with additional knowledge and skills that can complement many of the conversations they have with their customers while they sit in the chair.
“We did this to let people know how efficient it is to utilize barbers and hairdressers to empower the local community,” Resen said.
departure
Shackle Free launched in April 2019, but it wasn't an easy launch: One of the first things Lesene noticed when starting Shackle Free was the lack of comprehensive options to address people's health and social needs.
“Everything is pretty much siloed, nobody is working together, nobody is talking to each other,” she said.
The organization is largely grant-funded, but in the first year, most of its funding was self-funded, as Lesen and her colleagues worked hard to secure small grants of just a few thousand dollars.
Then, as the COVID-19 pandemic raged, Shackle Free played a key role in securing vaccinations in communities of color in eastern North Carolina. Data from the early days of the pandemic in North Carolina showed that Black people died from COVID-19 at a higher rate than non-Hispanic white people. Hispanic and Latino people had more than twice as many positive cases than non-Hispanic people. This led state health leaders to tailor vaccination outreach to the communities hardest hit by the pandemic.
Lesene, second from the left, with a group of Shackle Free Community Health Ambassadors. Photo courtesy of Shackle Free Community Outreach Agency
Shackle Free was one of 21 organizations selected in late 2021 by Healthy Together, a public-private partnership between the state Department of Health and Human Services and the N.C. Coalition of Counties, to support COVID vaccine outreach efforts and provide ongoing access to testing and personal protective equipment. The effort was conducted in partnership with barbers and cosmetologists to share information about COVID-19, the vaccine and its effectiveness.
The organization received a grant from U.S. Aging's Aging & Disability Vaccination Collaborative in 2023 to help organize community vaccine events in the five-county region, and with the support of area health care providers, Shackle Free organized the administration of 5,400 COVID and flu vaccinations.
Shackle Free used some of the grant money to equip several barbershops with tablets that feature a short questionnaire to screen for health and social needs, such as vaccine hesitancy, chronic health conditions, domestic violence, housing stability and food security, and then give customers the option to connect with a local health ambassador who can connect them with resources.
Building on that work, in 2024 Shackle Free received a $600,000 grant from the North Carolina Department of Information Technology to advance digital equity, the group's largest grant ever. Some of the money will be used to equip barbershops and salons with computers, Lesen said, so people can check their email or take part in telehealth meetings while they wait for their salon appointment, he added.
Although funding for Shackle Free has increased in recent years, Lesene recognises the need for more sustained support, and she hopes they will be able to attract even more philanthropic support in the future.
“We don't get much support from the local government,” Resen said. “It's a struggle for us.”
History of health advocacy
Sharing important information through barbershops and hair salons is not new. As early as the late 1970s, researchers were gathering information about hairdressers' unique caring role and the potential to train them as mental health advocates. For decades, hair salons were among the few independently owned businesses owned by Black people and women. Before and after the Civil Rights Movement, these salons served as important hubs of political activism and safe spaces for political organizing.
In the 1990s, public health researchers began studying the effectiveness of sharing health information in barbershops and beauty salons, and studies over that decade found that these places showed promise in educating people about cardiovascular disease, high blood pressure, and breast and cervical cancer screening.
At the time, these businesses were on the front lines of the HIV/AIDS epidemic. The 1990 film “DiAna's Hair Ego” documented South Carolina hairdresser DiAna DiAna's work to educate her community about safe sex practices and prevent the spread of AIDS. Received positive reviews in national media, the 30-minute film garnered support among organizers who wanted to highlight the impact of the AIDS epidemic on communities of color.
Shackle Free Buzz infographic credit: Shackle Free Community Outreach Agency
In the 2000s and 2010s, researchers implemented interventions in barbershops and beauty salons on a variety of topics, including HIV/AIDS education. A study evaluating behavior change following barber-led peer groups on safe sex practices found an increase in reported condom use among men who attended the groups.
Hypertension, along with education about prostate cancer screening, has been another successful target of barbershop interventions.
“There are a lot of other topics that are discussed in barber shops and hair salons that are very stigmatized, but barber shops and hair salons are one of the places where these conversations are happening,” says Laura Linnan, a behavioral scientist and community health initiative researcher at the University of North Carolina at Chapel Hill.
In the early 2000s, Linnan and a team of researchers from the University of North Carolina launched the North Carolina Advancing Education and Understanding (BEAUTY) and Health pilot project in Lee County. They found that advice from hairdressers about cancer and healthy habits led to lifestyle changes in the majority of salon clients.
In 2009, Linnan's team implemented the FITStop pilot program in the Raleigh-Durham area to understand the role of barbershops in promoting physical activity and reducing chronic health disparities among a group of primarily black men. The researchers found that men wanted to learn more about health topics such as physical activity.
While information is important, Linnan stressed the importance of the right message.
“The men[in the study]told us they felt they were portrayed very negatively in the media and in educational materials,” she said. “They wanted to see healthy men, healthy role models.”
Linnan said he thinks training institutions should count these sessions as continuing education credits to maintain interest in these programs.
“They're … strengthening their skill sets,” Linnan said.
Laying the foundations
Shackle Free was founded in 2019, but its roots go back to a summer camp for at-risk youth in Duplin County that LeCine and her husband, Ray, started while LeCine was working as the county's elections official. They started the camp in 2011 in response to high rates of juvenile crime and teen pregnancy. (In 2010, Duplin County's teen pregnancy rate was nearly double the state's.)
“This camp was born out of the pain I felt seeing young children die in Duplin County,” Lesen said of her motivation for starting the camp.
Lesen and her husband used the grant to provide summer activities, from basketball and football camps to video game rooms and supervised study halls, with college students volunteering as counselors.
She said Ray, the camp coach, served as an important role model for the children.
“He was a trusted messenger with the same issues and obstacles that they faced,” she said, “and he was open with them, and, you know, they welcomed him warmly.”
In May 2015, Ray was involved in a motorcycle accident that left him partially paralyzed. In the years that followed, Lethen learned a lot about navigating the health care system. The lack of resources and comprehensive services, Lethen says, opened his eyes to the needs of the community.
Ray died in June 2018 from complications from injuries sustained in the accident.
“These tests are the foundation of the programs we currently offer,” she said.
The ideal messenger
She teamed up with Duplin County barber instructor Benjamin Moore to start the nonprofit in April 2019. Moore had met Leseen and her husband through his work in Duplin County and wanted to get involved.
“She's the brains of the organization and I have the street knowledge,” Moore told NC Health News.
For Resene and Moore, Shackle Free's goal is bigger than any one problem. The common thread in Resene's work is to help communities become more self-reliant and, in her words, “reverse” poverty. She says one of the main strategies for this is addressing health and social needs.
“We really understand how health impacts poverty,” Resen said. “If we make sure that health care isn't an unnecessary burden, we can give[people]the opportunity to achieve their dreams, pursue their careers, be healthy and in employment.”
Moore is aware of this goal and realizes the unique power of the shared experience that connects Community Health Ambassadors with the people they serve. “It touches the hearts of people sitting in the same chair as me who are experiencing the same things I am,” he said.
Compared to other community voices, there is a special continuity to the relationships forged in barbershops and beauty salons.
“Some people rely on the same barber from birth until death,” says Lethen, “and those relationships continue through births, losses, health issues and so on.”
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