Despite equal hypertension awareness as white Americans, African Americans have a significantly higher hypertension prevalence and poorer control rates. Furthermore, the overall age-adjusted death rate related to hypertension in blacks is almost twice that than any other U.S. racial/ethnic subgroup [1,2]. Moreover, with the adoption of recent systolic/diastolic hypertension designation of greater than 130/80, the prior 42% of black men in the U.S. described to be hypertensive has now increased to as much as 59% [3].
The recent publication, “Sustainability of Blood Pressure Reduction in Black Barbershops,” by Ciantel A. Blyler et al., the 12 month benefits of their novel Los Angeles Barbershop Extension (LABP Extension) to controlling hypertension in this high-risk population [4]. Nevertheless, several important considerations must be addressed before widespread dissemination of this cluster-randomized trial to other locales nationally.
The LABP Extension clearly demonstrated the effectiveness of a community-partnered team comprising established barbers and clinical pharmacists, to control the hypertension of black males. The results indicated that the mean baseline systolic blood pressures were 152.4 mmHg and 154.6 mmHg for intervention and control groups, respectively [4]. In the intervention group, 68% of participants’ blood pressure decreased below 130/80 with the mean systolic blood pressure decreasing by 28.6 mmHg [4].
However, only 11.0% of the control group participants achieved the designated systolic pressure of 130/80 (pSpecifically, the reproducibility of the LABP approach may be limited due to its complexity, excessive costs, and restrictions on nation-wide dissemination due to the limited availability of the California-approved Collaborative Practice Agreement (CPA), giving the pharmacists prescriptive authority [5].
The two full-time doctoral-level LABP pharmacists were uniquely trained as hypertension clinicians, to measure accurately blood pressure using a validated oscillometric monitor, manage medications, encourage lifestyle change, and measure plasma electrolytes and creatinine [6]. The heterogeneous state CPA laws may limit what services the clinical pharmacist may perform in various localities [5].
One hallmark of the LABP Extension is the application of effective, contemporary, evidence-based pharmacotherapy, utilizing a two-drug regimen, as needed in most adults, especially blacks. This intensive antihypertensive treatment regimen used amlodipine and a long-acting angiotensin II receptor blocker, such as telmisartan or Irbesartan [3]. Moreover, the impactful third drug, indapamide has a similar efficacy to chlorthalidone, and a fourth drug, an aldosterone antagonist, have been shown to be superior in treating resistant hypertension [7].
On the other hand, the control group participants often lacked highly effective initial dual drug therapy and, compared to the intervention group, had significantly smaller number of BP medications per participant, including 12.0% versus 1.2% aldosterone antagonist (pBeyond the barbershop, primordial prevention is a necessary pathway to curtailing excess hypertension in black Americans. Despite the obvious need for effective pharmacotherapy, lifestyle modification (i.e. weight reduction, dietary modification, and increased physical activity) is critical in order to stem the shamefully disparate burden of hypertension-related death and disability among both black men and women [9].
Furthermore, personal beliefs, values, and culture are equally important determinants of effective blood pressure control [4]. As recently revealed, the “Southern Diet,” high in calorie dense foods (including fried food, organ and processed meats, high-fat dairy, and refined carbohydrates but few fruits and vegetables) is a key factor, accounting for approximately 52% of the excess prevalence of hypertension among African American men [9].
Moreover, 12.3% of black male excess hypertension risk was associated with higher salt intake and a maximum education level of high school completion. Nevertheless, the adoption of heart-healthy behaviors is often difficult in communities with fewer resources, adequate social supports, and prominent barriers to regular exercise, healthy diet, and effective medical care.
Los Angeles County is not the Mississippi delta or other disadvantaged urban areas and the LABP participants demonstrated potentially unique social and economic characteristics which may not reflect the great diversity of black populations and variation of cardiovascular disease throughout the country. One success of this trial is the use of clientele’s established long-term relationship with their barbershops, overcoming a potential source distrust [4].
On average, the barbershops in both the intervention and control groups were in business for approximately 2 decades, and the decade-long duration of patronage indicated strong established trust. Furthermore, despite being relatively socioeconomically disadvantaged, most of the volunteers were socially stable with approximately 50% either married or living with a partner, and only 4.5% of intervention and 8.6% control had less than high school education with almost half having some college or an associate degree [6]. Additionally, almost 80% of both control and intervention groups had some form of insurancemuch greater than that seen where black populations represent large percentages of the population in states especially in the South, where Medicaid has not been expanded [6].
While awaiting the results from further research in the LABP Extension, both societal and academic support should continue for present, ongoing initiatives, such as Target:BP. Using the M.A.P. framework, Target: BP collaborates with health providers to develop a customized plan and algorithm, in addition to best practices and patient education resources, to decrease patient blood pressures [10].
Furthermore, Million Hearts seeks to improve cardiovascular outcomes, including decreasing by a million the number of heart attacks and strokes in priority populations, using targeted protocols and medication adherence strategies [11]. When considering the unique benefit from the novel LABP project, it is necessary to reflect on the portability and reproducibility of the specialist clinical pharmacists, the social stability and insurance status of the LA barbershop patrons, and the probable excessive cost associated with the utilization and widespread application of this model. Nevertheless, it is reasonable to continue research seeking the best means to develop broad-scale implementation of the LA Barbershop specialty team approach.
Despite the novelty and apparent effectiveness of the LABP Extension, improved, standardized clinical treatment approaches may be a more practical and cost-effective solution to reduce uncontrolled hypertension in black men. One example of effective blood pressure control is the Kaiser Permanente (KP) coordinated team-based approach involving the primary care physician and an interdisciplinary support staff, emphasizing culturally tailored patient education to effectively address health behavior and improve adherence.
Similar to the LABP, the KP program uses evidence-based guidelines, medical assistant follow-up for blood pressure monitoring, and effective initial single-pill combination pharmacotherapy. Impressively, KP blood pressure control rates improved from 76.6% to 81.4% (using < 140/90 mmHg cutoff) for blacks, and from 82.9% to 84.2%. for white Americans. The racial disparity decreased from 6.3% to 2.8%. Promulgating their effective approaches in other established clinical settings nationally is a reasonable approach to hypertension control [12].
Researchers, clinical providers, public officials, and the lay public should continue to support these positive efforts funded by the National Heart, Lung, and Blood Institute’s (NHLBI) Center for Translational Research and Implementation Science. The center plans, fosters, and supports research to identify the best strategies for ensuring successful integration of evidence-based interventions within clinical and public health settings, such as health centers, worksites, and improved health strategies to reduce or eliminate both domestic and global health disparities in heart, lung, blood, and sleep disorders [13].
As reflected in a recent NHLBI Working Group report (2016) the use of non-traditional, non-clinical, settings, such as barbershops, faith-based organizations, or homes, for the delivery of team care is promising [14]. One benefit of the barbershop is that it represents a level of trusted care for men that church or faith-based sites do not seem to achieve.
Although a recent community-based lifestyle intervention in churches led to a significant reduction in hypertension in blacks, the cohort was 76% women, indicating the uniqueness of the barbershop for targeting men in a trusted environment., Overall, it is essential to determine how NHLBI community-based research may be used to reach vulnerable and high-risk black women and men in a sustainable and financially realistic manner.
As a society, effective blood-pressure control in high-risk black men with intensive antihypertensive medications is cost-saving and cost-effective in the long term. However, although encouraging, the benefits of the recent extension from the LABP randomized trial must be weighed against its complexity, generalizability to diverse black populations, and potentially high implementation expenditures.
