PROJECT BHAI (Barber Shop Based Health Awareness Initiative)

This project BHAI (brother) is based on an innovative concept of using barbershops as a network for health promotion activity in the community.

Project Site : Chaibasa Urban (Jharkhand, India) and Bhubaneswar (Orissa, India)

Duration of the Project : 2007-2012

Target Population : Male population in the two areas Chaibasa and Bhubaneswar

Agents of Change : Barbers (89) in the 1st phase

Setting for Intervention:

Project Team

Principal Investigator: Dr Sanghamitra Pati ,Bhubaneswar ,Orissa -751022. drspati@yahoo.com

Co investigator: Mr. Rajeev Ranjan, Chaibasa, Jharkhand-833201

Coordinators (Full time):

Mr Rohit Prajapati, Mr Rakesh Ram, Mr R.K Mishra, Mr Haribandhu Gouda, Mr U.K Mohanty

Supervisor and Evaluation

Dr Hrudananda Swain, Dr Tapaswini Das, Dr Sandipana Pati, Dr Jayanti Mishra

Collaborators:

Barber shop Association Members,Community Leaders,Local Media Personnel,Local Health care services

Consultants (Honorary):

Prof Sukdev Nayak (Oncologist),Dr P.K.Rathor (Family medicine), Prof Dr Saroj Ku Sahu (Community medicine) ,Dr Soumyakanta Das (Psychiatrist),Dr D.K.Panda (Laboratory Medicine),Dr G. Biswas (oncologist),• Dr Digaraj Brahma (Educationist) ,Ms Farhat Amin ( Media Consultant, TIMES group) ,Dr Meenkshi Panda (Sociologist),Dr BB Nanda (Data analysis)

PROJECT OVERVIEW

Background and Rationale:

India is a diverse country with strong difference in health across the population in respect to gender, education, socioeconomic status, ethnicity, and culture. To address the existing health disparities among various strata, we need to develop interventions that are culturally appropriate, acceptable, effective and accessible. In addition, the best community settings in which to deliver health education should be determined. Engaging trusted community representatives in health promotion activities could be an effective strategy in this regard. Barber shops hold enough promise as setting for health promotion in Indian context. They are located in every nook and corner of the country, accessible in all communities and frequented by on a regular basis. Needless to say, this setting offers important opportunities for both reach and reinforcement of health messages. Particularly, if we could design the suitable methods and intensity of delivering health promotion messages to the customers during their salon visit, the opportunity for reaching people and reinforcing these messages at subsequent salon visits will be enormous. Gradually the barber shops could become vital and sustainable links in health promotion.

Genesis

Present project is first of its kind to be undertaken in this part of the country. It was conceived in the month of June 2007, culminating from a study conducted on the identification of community health information portals (CHIP). The CHIP study showed that Barber shops, because of their accessibility and frequency of visits could be utilized as effective settings for dissemination of health information and health education and might be potential hubs in health promotion activity. A further study was conducted to gather information from both the perspectives of barber shop owners and customers on salon’s use for health education research. The results revealed that the client’s level of willingness to engage in health education activities equals that of the proprietor. It was also observed that customers were receptive to receiving information on a variety of health issues (cancer, diabetes, cardiovascular disease, arthritis) that impact the community through barber shops. Thus, it provided enough impetus for designing health intervention project in barber shops.

In the initial phase, the project would focus on chronic disease prevention education particularly; it will address the unmet needs pertaining to cancer prevention and tobacco control in the community. The local health services, barber shop association, media persons and community leaders have been approached for collaboration in this project and they have given very favorable and positive response.

Goal 1: Enhance knowledge about tobacco prevention and cancer awareness among the customers of participating barbershops

Goal 2: Enhance Healthy behavior among men attending the target barbershops with a particular focus on cancer prevention and screening and tobacco abuse prevention

Goal 3: Build on existing resources, partnerships and networks to facilitate and promote appropriate screening opportunities and referrals to local clinical and provide counseling services for the underserved population

Goal 4: Devise strategies to expand its domain of activities to other diseases (cardiovascular diseases, diabetes, arthritis) and other areas through leverage of logistic and financial support

Goal 5: Create an environment for sustainability of the Barbershop based Health Awareness Initiative through advocacy and dissemination of project results adopting multiple approaches.

Evaluation:

Multiple methods will be adopted to evaluate the project – data collection, process evaluation, outcome evaluation, ongoing monitoring, feedback from the customers and barbers by focus group discussion.

Time plan:

Current Status:

Currently the information, education and communication materials for the project are under preparation. All these materials will be pretested, modified, and would be utilized for intervention. We are in need of donors and sponsors to bring out the hard copies and procure IEC accessories for dissemination.

Funding: Estimated Budget: 17,000 US$ (seventeen thousand dollar only) 2009-2010

Till now, the project is being taken care of by self generated funds from the project coordinators. Few individual grants (patrons) have also helped to arrive at this stage. Currently, we are seeking regular and adequate funding for at least next two years to make the project sustainable and effective.

Future Growth Strategy:

In the initial phase this project is undergoing at two areas i.e. Chaibasa (Jharkhand) and Bhubaneswar (Orissa). These two states are among the backward provinces of India in terms of health, education and development. Subject to availability of funding, our project would expand its spheres of activity and encompass other rural, semi urban and urban areas of the two states in its intervention. The project also intends to advocate for accreditation of barbershops who participate in such health promoting activity. This would in turn ensure the sustainability of the initiative and also create a tradition of health promoting environment in the society through barbershops acting as linking pins.

Project SAHELI (Salon based Health Literacy for Women)

This innovative project titled SAHELI (Lady friend), first of its kind to be taken up in the state, is a cancer awareness generation program using women’s beauty salons as a setting for delivering cancer prevention education.

The project SAHELI got started in the year 2007. At present, preliminary assessment and feasibility study are being conducted in three towns of the state Orissa: Bhubaneswar, Cuttack and Berhampur.

Project Director: Sanghamitra Pati

Project Coordinators:

Dr Jayanti Mishra , Dr Sandipana Pati, Dr Tapaswini Das, Mrs Jyoti Kar, Mrs Surama Mohanty, Ms B.P Tripathy, Mrs Snehalata Mohapatra, Mrs Mamata Satpathy, Mrs Rajashree Chintak

Resource Persons:

Dr Meenkshi Panda, Prof Sarojini Sarangi, Prof Pratibha Kanungo, Prof Sukdev Nayak,

Need for the Project and Community Relevance

Breast and Cervical cancer are the most common malignancies and the leading cause of cancer death among women in India. Indian women are at higher risk of dying from breast and cervical cancer, in part because of late diagnosis. Studies suggest that lack of relevant information on prevention, early detection, and lower screening activity rank among the major contributing factors. Interventions to increase cancer screening among women could lead to a considerable reduction in the cancer related morbidity and mortality. This requires community-based approaches and identifying innovative settings within communities that reach large numbers of underserved women. Literature suggests that generally, women are most likely to receive health related information from trusted sources.

Beauty salons hold a promising setting for creating health related awareness among women across the world. In India, at present, salons are possible candidates for a health promotion and education site due to their significant social and cultural roles. Salons are located in every nook and corner of an Indian town, their number being much more than that of pharmacies and health centers together. With progressive urbanization, more and more women are seeking salon services presenting an opportunity for widespread and regular dissemination of health related information. In the western countries, various projects have used beauty salons for community health promotion with success. However, such projects are yet to be taken up in India. In Indian scenario the present work is first of its kind to explore the potential of beauty salon for the delivery of cancer prevention messages.

Beauty salons as a setting for delivering cancer prevention education among women: A feasibly assessment (2007-2008)

This study using community based participatory research, tried to identify the levels of interest in health promotion activities among beauty salon owners and their customers, discuss types of interventions acceptable to beauty salon clients, design intervention opportunities for salon personnel and the service users through observation of informal communication between beauticians and clients in the salon environment.

Phase I: Needs assessment of Local Women in relation to Cancer Prevention Information

Data was collected on the opinions of women customers of randomly selected beauty salons in the Bhubaneswar town, Orissa to assess their willingness to receive health education with special focus on cancer prevention and their preferred modes of communication. Majority of clients felt they are not getting the requisite information on cancer prevention from their physicians and local health authorities. They indicated that they would be interested to receive health and nutrition related advice from their beauticians and get the cancer screening information in different forms (written communication, advice from beauticians, audio and video presentations). They were interested to know the basic procedure of self breast examination from a trusted source.

Phase II. Beauty salon owner study (quantitative)

A survey was conducted to estimate the total number of formal and informal beauty salons, their location, and facilities, services offered, customer load among the beauty salons of the Bhubaneswar town. 68 randomly selected salon owners were administered a questionnaire asking about the duration of their business, educational status, income, type of customers, peak hour and day of customers, average time spent by customer, and frequency of customer visit. It was gathered that the Health topics of greatest interest to salon owners include: cancer prevention and prevention of chronic diseases, healthy eating, achieving/maintaining a healthy weight, and reducing stress. Salon owners believe that participating in a health promotion work will enhance future business; improve salon reputation in the community and, would recommend participation in such study to other salon owners .

Phase III. Focus Group Discussions with Salon owners (Qualitative)

Seventeen randomly sampled beauty salon proprietors in Bhubaneswar, Orissa were interviewed in detail to assess their willingness to allow their clients to participate in health education research, and to find out different methods of delivering cancer prevention messages to their customers. Almost all the salon owners reported that their clients seek advice relating to diet, skin and hair care from them. Nearly all of the proprietors (97%) said they would be interested in promoting the local women’s health in their salons. They thought it could give a boost to their business and increase the status of their salons. Of the salon clients surveyed, 93.0% reported interest in cancer screening information and 86.5% preferred receiving information in brochures and pamphlets. Ninety percent of respondents wanted to know about breast health examination and learn under the guidance of a health care person. All the salon owners considered allowing their clients to obtain health related information in different forms (posters, stickers, pamphlets, audiovisual materials) made available through their salons. The data indicate that it is feasible to work with beauty salon proprietors; and that salon owners and clients want to receive health information in this setting.

Phase IV. Dynamics of customer-client interaction in the beauty salon environment

The informal conversations between beauticians and clients were observed to explore what happens naturally between the cosmetologist and customer in a salon and thus assess features of the salon environment that might be used to design the development of salon-based health promotion interventions. Results revealed that the social environment of a salon is a place where beauticians and customers talk openly about many subjects, including health. Information, advice, appraisal, humor, and empathy are typically shared in these natural talks. Several features of the physical environment of the salon may be mobilized to support health; with special focus on access to cancer prevention information; and availability of print or video materials, signs, or displays that include healthy messages.

Overall conclusion and Project Implications

The results of this assessment study indicate that salons could be a potential place for promoting health and identify important leverage points for intervening to prevent cancer among women in the community. The results are encouraging enough to plan interventions for salon-based health promotion and cancer prevention --including the training of accredited beauticians to deliver appropriate health messages could be undertaken.

PROJECT MANASHI (My Woman): Mahila Samiti Network (women’s self-help groups) as Health Information Portal

This novel concept is intended to utilize the self-help groups (SHG) networks as setting for health promotion and channel for dissemination of cancer related information among the women in rural and remote areas. SHGs are emerging as important stakeholders in women’s’ development. They could be potential informal network for facilitating health promotion as well. This project MANASHI (my woman) is a unique project taken up to generate cancer related awareness among rural and remote women through the SHGs. It was initiated in August 2008 and at present undergoing at two sites of Orissa.

Project Site: Puri Municipality and Bhingarpur Village

Project Director: Dr Sanghamitra Pati

Chief Coordinator: Dr Meenkshi Panda

Coordinators: Dr Tapawini Dash, Dr Arpita Mohapatra, Ms Puspanajali Mishra, Ms Jayashree Tripathy, Mrs Debabbala Pangrahy, Mrs Sanjukta Dash.

Identification of cancer information dissemination sites for women in Orissa (2007)

Cancer is one of the major causes of premature mortality and morbidity in Indian women. Although early detection of cervical and breast cancer has received a great deal of attention, there is minimal awareness among the women of its importance. Research suggests that health education and health promotion interventions should focus on improving knowledge, beliefs and attitudes as well as addressing any distrust and fears that act as barriers to health promotion. To address the low uptake of cancer screening among women, culturally sensitive and relevant community-based approaches to health education are needed. Moreover, the ideal community settings to deliver cancer related education should be identified. Present study was conducted to identify specific places within a suburban community that have the potential to be sites for imparting cancer prevention education. These sites, termed cancer information dissemination sites (CIDS) were determined using the guidelines of socio-spatial networks. The target population for the study was the women residing in the suburb locality of Bhubaneswar, Orissa. Those who had a cancer patient in their family were excluded from the study. 480 respondents were interviewed in detail regarding the places they visited in carrying out their daily activities. Data on number of visits to specific sites, degree of familiarity with these sites, and ratings of sites as places to receive cancer related messages and information were used to identify dissemination nodes. Primary sites of importance included: beauty salon, pharmacy, and places of worship, market place, women’s society, nearest GP clinic, traditional healers, and municipal medical dispensary. These sites could be effective portals for dissemination of cancer prevention information with sustainable impact. The results could be utilized towards design of cancer prevention programs for urban community

Integration of Cancer screening training into Nursing Education (2007)

This pilot project initiated cancer screening education component in nursing training. Final year nursing students were imparted a module on basics of cancer screening and early detection methods relating to common cancers and tobacco counseling with an aim for application in their forthcoming career as a nurse practitioner.

Physicians practice of cancer prevention education in primary care (2006)

Cancer is emerging as a leading health problem in India. Primary care physicians are a critical source for communicating important cancer screening recommendations and play a significant role in increasing the cancer screening behavior of their patients. This exploratory study assessed and evaluated the practice, attitude and barriers related to appropriate and effective cancer screening communication by the physicians in Orissa. It also sought to identify the factors associated with the likelihood of physicians making appropriate and persuasive cancer screening recommendations and to assess primary care physicians' perceptions of cancer risk in their patients. Primary care physicians practicing in the Orissa state were administered a questionnaire survey on their medical practice characteristics, patient communication, cancer screening guidelines, cancer risk perception, and demographics. Results showed that physicians hardly provide any cancer screening recommendation to their patients and they did not consider it a significant component of their job. Cancer prevention education was enlisted as one of the low priority jobs among the interviewed physicians. Smoking and tobacco abuses are dealt with casual attitude. They attributed the reasons as: inability to get ample time, patient overload, less risk perception, inadequate facility for cancer screening and lack of cancer risk communication skills. Most of the respondents felt it is not possible for the primary care physicians to provide cancer screening information as they are hard pressed with handling indoor, outdoor and emergency cases. Moreover vaccination and health clinic management also add to their schedules. However, majority physicians expressed their willingness to supervise community-based alternate cancer prevention programs on weekly or monthly basis. The findings from this study provide pertinent information toward the development of alternate or complementary interventions for cancer prevention education to the community.

Barriers to cancer screening behaviors among women in Orissa (2005)

This particular research attempted to identify some of the factors that act as barriers to uptake of breast and cervical cancer screening services among Oriya women. A series of focus group discussions were held among women in rural, suburban and urban Orissa to discover their perceptions of cancer screening, the barriers to effective uptake and some strategies for intervention. Analysis of focus group data has revealed poor knowledge, lack of informed attitude, low risk perception, less perceived vulnerability, underlying health and cultural beliefs, inadequate physician-patient communication, and uncooperative attitudes of health professionals to be important barriers. Women with more fatalistic and fearful attitudes towards cancer were less likely to have had a screening test done. In terms of strategies for effective intervention, the most popular strategy for improving uptake of screening services was community-based cancer awareness education that is consistent with our socio-cultural beliefs. It is essential to identify a strategic community based setting to reach out women and provide cancer prevention information.

Young Women’s Knowledge of and attitude towards Breast cancer in Urban Orissa: Implication for Program Intervention (2004)

Breast cancer is the second leading cancer seen among Indian women. Self breast examination, clinical examination and mammography could facilitate in early detection and thus help preventing the magnitude of morbidity and mortality. This study investigated the knowledge and attitude of Oriya women aged 18-30 years on clinical features, risk factors of the breast cancer as well as screening programs such as breast self-examination (BSE), clinical breast examination, mammography (MMG). First, baseline data from a larger study on cancer prevention among urban and suburban communities in Bhubaneswar were used to assess predisposing and enabling factors associated with mammography use. Lower education levels, not having regular access to a doctor, having had a male doctor, lack of information on the availability of the screening facility, cost of the method were inversely associated with mammography use. Furthermore, women in low socioeconomic strata expressed fear of finding cancer, as a reason for not undergoing screening exams. Qualitative interviews were conducted among women to characterize their social networks and to understand how social support may be related to receipt of screening for breast cancer. Women who had a breast health check up for a suspected lump within two years had larger social networks compared to women who never had a screening done. The most common persons to be mentioned in the network were peers and elder siblings. Perceptions of fear and pain toward mammography were also prevalent. There is a need for creating awareness on breast health examination among young women.

A study of the awareness of screening procedures for cervical cancer (pap smear) amongst health service users in a suburb area of Bhubaneswar, Orissa, India (2004)

Cervical cancer is the most common causes of cancer mortality among women in India. There is limited information on breast and cervical cancer knowledge, screening practices and attitudes of women in Orissa. This work studied the awareness of cervical cancer screening among female patients attending the municipality health centers located in the suburb area of Bhubaneswar, Orissa. The participants were interviewed on their knowledge of cervical cancer in general, its risk factors as well as utilization of Pap smear as a screening test. None of the interviewed women knew when they should begin cervical cancer screening. The primary reason for doing a Pap smear was because the physician asked them to do it. Majority of respondents displayed willingness to participate in the screening exercise. The study showed that knowledge of cervical cancer is still poor and there is very low information of risk factors among urban women. It is suggested that community based cancer education needs to be initiated for urban women to make them aware of the importance of screening practice, warning signs & symptoms and risk factors.

Knowledge, Behavior and Perceptions regarding Cervical Cancer among Women in Rural Orissa (2004)

Cervical cancer is a leading cancer among Indian women with considerable morbidity and mortality. Although quite a few studies have documented the low participation level of rural women in cancer screening in India, few have examined their predisposing knowledge and attitudes concerning cervical cancer. This study was taken up to explore the knowledge and risk perception regarding cervical cancer among a rural women population of Orissa and their impact on cancer screening behavior. The study observed a difference in knowledge and attitude across the study population depending on age, education, socioeconomic status, literacy level. The low screening participation among rural Oriya women is primarily due to their limited awareness and knowledge about cervical cancer and its screening procedures. This study highlights the need for wide-scale cancer screening education to address the specific requirements of rural women.