Introduction

The SARS-CoV-2 (COVID-19) pandemic has had a devasting impact on global public health with the United States carrying a significant burden with over 44 million cases and over 710,000 deaths since January 2020 [1]. Together with a long overdue racial reckoning, COVID-19 has laid bare health disparities in the Black community in the United States, with African Americans suffering from disproportionally higher COVID-19 morbidity and mortality rates [2, 3].

Engagement of trusted community partners is more critical than ever for successfully addressing these disparities. This is especially true during the COVID-19 pandemic for public health strategies like community-based testing, contact tracing, and vaccination [4, 5]. One such partner is the Black barbershop.

Black barbershops have historically played a public health role far beyond haircuts because they form a culturally-safe space of social cohesion [6,7,8]. Barbershop-based interventions have previously successfully tackled prostate cancer, hypertension, diabetes, cardiovascular disease, and sexual health [9, 10]. However, little is known about the impact of COVID-19 and stay-at-home-orders on Black barbershops, or their role in the current crisis. We surveyed barbers in Black barbershops across the US, to better understand how these community pillars were impacted by COVID-19 and their potential role as public health extenders during the pandemic.

Methods

In this cross-sectional study, we disseminated a 30-item survey to a convenience sample of predominantly Black barbershop owners and barbers across 40 different states/territories in the United States. The survey was developed and piloted in partnership with Black barbershop leads of the Cut Hypertension Program (CHP) [7], that addressed the impact of COVID-19 on Black barbershops, and barbers’ interest in engaging in health outreach programs [11]. The electronic Qualtrics survey was disseminated through the CHP website between June and October 2020. It was also distributed via a national network of barbers and prominent social media channels (Facebook and Instagram) geared toward predominantly Black barbershops. We did not specifically ask about participation in CHP or have participation in CHP as a stipulation for completing the survey. Furthermore, we did not have access to the demographics of the social networks targeting Black barbershops. To incentivize participation, we raffled hair clippers for those who completed the survey over a four-week period in September 2020. Survey data were analyzed descriptively using Microsoft Excel® and R.

Results

Barber Demographics

A total of 112 barbers from 31 different states/territories responded to the survey, with the largest proportion of responses coming from the States of California (n = 17; 15.2%) and Mississippi (n = 12; 10.7%). Most respondents identified themselves as men (n = 91; 81.3%) and Black (n = 80; 71.4%). Respondents represented the following age groups: 18–30 years (n = 32; 28.6%), 31–40 years (n = 34; 30.4%) 41–50 years (n = 41; 36.6%), and 51–60 years (n = 2; 1.8%). The majority were the main provider of the household (n = 82; 73.2%) and the mean reported family size was 3.9 persons/household, slightly larger than the US mean (3.1 persons/household). Only a minority of barbers had completed college with a bachelor’s degree or higher (n = 17; 15.2%). Health insurance sources were diverse: private (n = 26; 23.2%), public (n = 29; 25.9%), self-purchased (n = 28; 25.0%), and uninsured (n = 26; 23.2%). Table 1 presents all participating barbers’ demographic information.

Table 1 Participating barbers’ demographic information (n = 112)
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Impact of COVID-19 on Barbers and Barbershops

Prior to the pandemic, most barbers reported seeing between 1 and 20 clients per day (n = 94; 83.9%). Specifically, 45 barbers (40.2%) responded they were seeing 1–10 clients and 49 (43.7%) responded they were seeing 11–20 clients. The overwhelming majority of barbers (n = 93; 83.0%) reported that the COVID-19 stay-at-home orders had a significant to severe impact on their business, yet only 5 barbers (4.5%) responded feeling very prepared against financial hardship due to COVID-19. Almost half thought they met requirements for federal government relief (n = 47; 42.0%) or state unemployment benefits (n = 50; 44.6%). Only 13 barbers (11.6%) thought they would be able to keep their business viable for 3 months or longer during the COVID-19 stay-at-home orders, while many (n = 48; 42.9%) were unsure how long they would be able to keep the business running. Furthermore, 65 barbers (58.0%) thought they would lose ‘some’ or ‘many’ clients due to the pandemic. Lastly, 60 barbers (53.6%) thought at least ‘some’, ‘most’ or ‘almost all’ barbers were continuing to cut hair during the stay-at-home orders, but only 33 barbers (29.5%) believed that barbers were always using personal protective equipment (PPE). Table 2 presents findings on the impact of COVID-19 impact on barbers and barbershops.

Table 2 Barbers’ survey responses (n = 112) on COVID-19’s impact on barbers and barbershops
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Needs and Assets of Barbers for Continued Outreach

More than half (n = 66; 58.9%) of barbers reported providing some kind of community service outside of barbering prior to the COVID-19 pandemic). The most common services were: supplying health-related information to clients (n = 30; 26.8%), blood pressure and health screenings (n = 29; 25.9%), literacy programs for children (n = 17; 15.2%), and collecting food donations (n = 16; 14.3%). Most barbers (n = 92; 82.1%) reported stable or increased interest in engaging in health outreach programs in collaboration with universities, community clinics, and hospitals/health care to provide health outreach and education. Additionally, 75 barbers (67.0%) thought they have either similar or significantly improved communication with their clients, despite COVID-19. Eighty-two barbers (73.2%) felt somewhat or very prepared to re-open or remain open during the pandemic. Barbers identified the following top 5 services that would help them feel better prepared to remain open or re-open during the COVID-19 pandemic (in ranked order): PPE (n = 94; 83.9%), sanitation guidelines (n = 85; 75.9%), signage and educational materials for customers to prevent the spread of COVID-19 (n = 76; 67.9%),COVID-19 testing for customers (n = 66; 58.9%), and easy access to a health care provider or community program for questions (n = 43; 38.4%). In addition to these services, when asked how academic medical centers might help during COVID-19, barbers also identified “informational package for barbers and clients about COVID-19 precautions” (n = 54; 48.2%). Table 3 presents our findings on barbers’ perceived needs and assets for continued health outreach.

Table 3 Barbers’ survey responses (n = 112) on their perceived needs and assets for continued health outreach
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Discussion

Impact of COVID-19 on Predominantly Black Barbershops

Our findings suggest that COVID-19 and the resultant government-mandated shutdown had a negative impact on the livelihood of barbers working in predominantly Black barbershops and their families. National data have shown that minority-group business owners have been disproportionately affected by the COVID-19 pandemic. While the overall number of active small business owners dropped by 22% between February and April 2020, the drop was greatest among Black-owned (41% drop), Latinx (32% drop) and Asian businesses (26% drop), with the number of white-owned business owners dropping by 17% [12, 13]. Our data showing the paucity of respondents thinking their business would weather the COVID pandemic for more than 3 months is in line with these national trends. Despite the shutdown, some barbers in our study reported that, in an attempt to lessen the pandemic’s toll on their livelihood, barbers continued to cut hair but with inconsistent PPE use. This potentially exposed themselves, their clients, and families to COVID-19, particularly since Black-owned businesses were often situated in areas with higher COVID-19 rates than White-owned businesses [13]. Many barbers in our study also did not qualify or were unsure whether they qualified for additional government aid, and had minimal financial reserve to weather extended stay-at-home mandates, similar to other Black-owned small business owners nationwide [13]. In fact, the payment protection program (PPP) [14], a large government relief program to help small business owners stay afloat during the pandemic, distributed funds to < 20% of claimants in counties with higher concentrations of Black-owned businesses (national average: ≈70%) [13].

Dissemination of Evidence-based COVID-19 Information and Vaccine Hesitancy

Aside from the financial impact of COVID-19, morbidity and mortality rates due to COVID-19 have also disproportionally affected racial and ethnic minority groups in the US, including African Americans [2, 3]. This could be partly explained by a higher prevalence of pre-existing comorbidities, but also lower income, insurance coverage rates, subsequently poorer access to health care services, overcrowding and use of public transportation [2]. In the context of COVID-19, understandable historic distrust in health care among Black community members [3, 15, 16] can result in less evidence-informed COVID-19-related information reaching these communities, thereby increasing the risk of contracting and transmitting the disease [2]. Moreover, African Americans have demonstrated more vaccine hesitancy and distrust, and thus decreased COVID-19 vaccine uptake, as has also been shown in the past [3, 15, 17,18,19]. Ensuring that credible and transparent information on the benefits of vaccination, disseminated by trusted sources in the community, is just one way of seeking to provide equitable vaccine access to all.

Barbers Tackling Misinformation

Tackling misinformation and alleviating distrust through barbers is a potentially impactful strategy to disseminate COVID-19 information, facilitate clients’ vaccination awareness and access to the COVID-19 vaccine. Barbers are the key individuals that expressed a stable or increased interest in partnerships with universities, community clinics, and hospitals/health care. The barbershop could serve as a safe place for trusted community outreach to disseminate such information and services [4, 10]. In fact, a growing body of evidence has shown that community-based outreach programs delivered via Barbershops are effective at bringing health information and public health interventions to vulnerable and hard to reach groups/underserved communities. Previous studies have shown the significant impact of such initiatives in, for example, the prevention and monitoring of cardiometabolic diseases [20, 21], prostate cancer screening [22] and HIV prevention [23].

In our study, many barbers were already engaged in health outreach in Black communities and were even more committed to partnering with the public health and health service delivery system as public health extenders, despite the challenges they faced as a result of COVID-19. Barber-administered health education and promotion along with direct linkage to health systems should be a focus in designing interventions to prevent the spread of COVID-19 and future variants. Future research should examine how to best implement barbershop-based COVID-19 public health interventions, while supporting them to safely keep their doors open to the Black community, including providing the necessary PPE. Furthermore, studies may also evaluate the essential nature of barbering as it relates to the health impacts of limited barbering in black communities as has been suggested by our research during the COVID-19 pandemic.

Strengths and Limitations

This study was a cross-sectional convenience sample of barbers across the United States seeded in part within a barber hypertension outreach program (CHP) with no access to non-respondent demographics, therefore we must be careful not to generalize our results. Nonetheless, this is the first snapshot of Black barbershop perspectives on the impact of COVID-19 and barbers’ role as public health extenders in this context, and is therefore an important part of the literature around the experience of Black communities and Black professionals during COVID-19. Our results are consistent with prior studies of Black barbershops as a community-based place of reaching Black members of the community across a variety of conditions.

New Contribution to the Literature

This focus on the financial and health impacts of COVID-19 in the context of Black barbershops is novel in the literature. Black barbershops, a well-documented effective partner in public health outreach to the Black community for many other chronic diseases, show promise as public health extenders in response to the COVID-19 pandemic.