Chronic kidney disease is serious, common, and costly. One in nine individuals 20 years of age or older have chronic kidney disease (1), which if left untreated usually leads to total kidney failure. Furthermore, an estimated two-thirds of individuals with undiagnosed and untreated diabetes and hypertension, both of which are associated with obesity (2), will develop chronic kidney disease (3). Nationwide, diagnosed and undiagnosed diabetes affect approximately 17 million adults (4), and diagnosed and undiagnosed hypertension, an estimated 65 million (5). In Michigan in 2004, the most recent year for which data are available, diabetes and hypertension accounted for more than 70% of all cases of kidney failure (6). African Americans, who are disproportionately affected by chronic kidney disease, develop hypertension earlier in life than do whites, and their average blood pressure is higher. As a result, the rate of kidney failure is more than 4 times higher for African Americans than for whites (3), and the rate of end-stage kidney disease is 4 times higher (5). With early detection, many, if not most, cases of kidney failure caused by diabetes or hypertension can be prevented or delayed (7). Educating and motivating the population at risk is vitally important. Lifestyle changes to prevent diabetes and hypertension and appropriate treatment of these conditions to reduce the risk of serious complications, such as chronic kidney disease, save both lives and money (8-10).

Numerous public health interventions exist to increase awareness of health issues and to promote behavior change. One particularly promising intervention is the use of lay health advisors (also known as community health workers, peer educators, and lay health workers). One study found that using lay health advisors in combination with a media education campaign was more effective than a media campaign alone in promoting screening for cervical cancer (11). The use of lay health advisors has also been shown to be effective in promoting cancer screening, prevention of sexually transmitted diseases, and smoking cessation among minorities and in immigrant communities (12-16). A study by Flax and Earp (17) suggests that lay health advisors influenced the individuals they counseled because the clients knew the advisors well, felt comfortable talking with them about private issues, and considered them credible sources of information.

This article describes the implementation of a lay health advisor program by the National Kidney Foundation of Michigan (Michigan Kidney Foundation) to increase awareness, promote healthy living, and reduce diabetes, hypertension, and chronic kidney disease in the African American community.

Approximately 14% of the population living in Michigan is African American. Despite being a relatively small proportion of the population as a whole, African Americans account for 47% of patients on dialysis and 40% of those on the kidney transplant waiting list (6,18). At 354 cases per million people, the annual rate of new cases of chronic kidney disease in Michigan is 5.4% higher than the national average (3). In 2004, diabetes and hypertension, the two leading causes of chronic kidney disease, accounted for more than 70% of all cases of kidney failure in Michigan (3).

Residents in low-income, minority communities have a particularly difficult time engaging in behaviors that can prevent chronic disease. REACH 2010 Surveillance for Health Status in Minority Communities (REACH), which provided data on risk behaviors in 21 communities including Detroit, Michigan, reported that in 2001–2002 minorities were more likely than the general population to be in fair or poor health but not seeing a doctor because of cost (19). REACH also found that the prevalence of eating five or more servings of fruits and vegetables daily and meeting recommendations for moderate or vigorous physical activity was lower for min ority adults than for adults nationally.

The Michigan Surgeon General's report states that as of 2002, approximately 62% of adults in the state were either overweight or obese, and Michigan ranked third highest among the states for obesity (20). Obesity rates were highest for individuals aged 35 to 74 years, African Americans, those with less than a college education, and those with a household income lower than $35,000. African American women have consistently had the highest prevalence of obesity in Michigan.

To promote health and reduce diabetes, hypertension, and chronic kidney disease in the African American community, the Michigan Kidney Foundation developed a campaign called Healthy Hair Starts with a Healthy Body (Healthy Hair). The Healthy Hair program began in Detroit in 1999 and relies on hair stylists to educate African American men and women about their disease risks and to help motivate them to adopt behaviors that can lower their risk. This intervention is based on previous work suggesting that individuals, such as hair stylists, who have an established rapport with their clients, can be effective lay educators. Healthy Hair trains African American hair stylists to promote healthy behaviors among their clients through a "health chat," educational materials, and risk assessment information. This project was conducted with approval by the Institutional Review Boards of the University of Michigan Medical School.

The program recruits stylists through direct mailing and personal contact by program staff and current participants. Recruiters appeal to individual interest in improving personal and family health, to community-mindedness, and to the desire to improve business. In a two-part workshop, stylists learn to motivate their clients to make lifestyle changes that can prevent kidney disease, diabetes, and hypertension and to seek medical advice. The workshop emphasizes techniques for motivating clients to improve health behavior and provides instruction on nutrition and exercise.

The workshop follows a curriculum (Appendix A) developed by the Michigan Kidney Foundation in concert with a statewide technical advisory committee, but the content is presented by experts, such as physicians and nutritionists, recruited from each local community. Program coordinators are allowed some latitude on content, and some have included a motivational speaker or a hands-on cooking demonstration to further motivate trainees. The training workshop lasts 4 hours each day and takes place on two consecutive Mondays, traditionally stylists' day off. From there, 12-week campaigns are launched.

The centerpiece of the Healthy Hair salon intervention is the "health chat" offered by stylists (Appendix B). This motivational appeal highlights disease risk factors faced by African Americans and asks clients to take one or more prevention steps: improve diet, increase exercise, stop smoking, or take medication if the client has already been diagnosed with diabetes or hypertension. Stylists also encourage clients to talk with a doctor about their risk for disease, to seek a blood glucose test and urinalysis, and to have their blood pressure measured, as warranted by existing risk factors. Clients complete a risk survey (e.g., the American Diabetes Association's Take the Test and Know the Score) as part of the first health chat. American Heart Association videos that reinforce the motivational content are shown at the discretion of the stylist and may not be used in all salons. Educational brochures, posters, and decals reinforce the stylist's message.

At the end of the health chat, the client completes a self-administered survey instrument called a Chat Form, which asks about clients' intentions regarding disease prevention and seeking the advice of a physician. The Chat Form serves as the primary tool for evaluating program outcomes. When the client returns approximately 1 month later, the stylist engages the person in a second health chat, and the client reports successes to date on Part 2 of the Chat Form (Chat 2). Other collected data include disease risk factors, diagnoses, and numbers of clients approached with the campaign message. Six months after the intervention, program staff conduct a telephone survey to identify the potential longer-term impact of the program.

Clients receive a healthy soul-food cookbook at their first visit, and upon completion of Chat 2, they receive a canvas bag containing beauty products and other incentives. Certified diabetes educators telephone clients scoring at high risk for diabetes to encourage them to see a doctor and to reinforce prevention behaviors. Clients at moderate risk are contacted by mail and urged to practice healthy behaviors and to be tested for diabetes.

Stylists receive a $50 stipend for attending the workshop and $4 for each completed Chat Form. They are also offered the opportunity to develop additional leadership skills by serving on a Partners Group, which advises on local campaign issues, including selecting training venues, recruiting volunteer trainers, and accessing local media and resources, and through occasional media and public speaking opportunities. Some veteran stylists go on to assist with campaign training. The estimated cost of the Healthy Hair program, including both direct and indirect costs, is approximately $45 per client served.

Between 1999 and 2005, the Healthy Hair campaign trained nearly 700 stylists and reached more than 14,000 clients in eight Michigan cities: Detroit, Flint, Grand Rapids, Lansing, Muskegon, Pontiac, Saginaw, and Southfield. General characteristics of clients who have participated in the Healthy Hair program are shown in the Table. Both clients and stylists report that the experience is effective and rewarding. Furthermore, self-reported information collected through the Chat Form suggests a number of positive behavioral results. For example, descriptive analyses of data collected on 8148 clients show that of those who indicated at Chat 1 that they planned to eat healthier (n = 7715), 46% reported at Chat 2 that they had increased their fruit and vegetable consumption, were choosing low-fat foods, or were limiting their salt intake. Of those who planned to exercise regularly (n = 6738) at Chat 1, 91% reported at Chat 2 that they continued to exercise at least 3 days per week or more; 32% reported that they had increased the number of days per week in which they exercised. Finally, of those at Chat 1 who indicated that they intended to either eat healthier or exercise regularly, 4545 (56%) reported at least one of the following lifestyle improvements at Chat 2: increased level of exercise, eating more fruits and vegetables, choosing low-fat foods, or limiting salt intake. Besides taking prevention steps, more than 2700 clients reported talking with their doctor during the campaign about their risk for diabetes, hypertension, and kidney disease. Approximately 1750 clients were tested for at least one of these conditions, and 190 were diagnosed with one or a combination of these diseases.

The responses of 60 clients from two cities to a 6-month postintervention survey conducted in spring of 2003 were encouraging both in the number of days of exercise reported and in the number of servings of fruits and vegetables eaten per day. Approximately 60% of survey respondents reported exercising at least 3 to 4 days per week, whereas 41% of the entire cohort reported this behavior at the completion of Chat 2. Eighteen percent reported eating at least five fruits and vegetables per day, a behavior reported by 8% at Chat 2. In one city, 89% of respondents reported limiting salt, and 70% reported limiting fat, rates that surpassed those reported 5 months earlier at Chat 2 and contrary to an expected dip in prevention commitment over time. Moreover, 50% of respondents in each of the two cities reported that campaign information prompted them to change the way they cook for their families, and 70% cited improved shopping habits (e.g., reading labels, selecting lower sodium foods, buying more vegetables). Of note, 75% of those contacted referred to an enduring campaign message that reflected improved knowledge and skills or reinforcement of healthy behaviors. Survey results also helped determine areas for improvement, such as the inclusion of educational brochures for clients to share with their families about healthy eating and cooking.

Many stylists also reported making personal changes in health behavior and said that their businesses have been helped in some way, including improved rapport with clients and a more positive salon atmosphere. In fact, because of the positive experience, several Detroit stylists suggested offering a second phase with different tools and methods. This appeal prompted discussions with statewide technical advisors and funding agencies about appropriate protocols for a follow-up campaign, and a new campaign called Personal Guide to Leading a Healthier Lifestyle, or Phase 2, was generated. Although the original Healthy Hair program was designed primarily to target women, a number of male clients participated in the program. To better address the needs of African American men, we have developed a program with barbers as lay educators. We are now pilot testing this program in several cities.

Nearly 60% of clients reached by a stylist in the Healthy Hair program reported having taken steps to prevent the targeted diseases or to seek medical advice. Given this outcome, we believe that the intervention is effective in the short term in bringing attention to healthy behaviors and increasing risk awareness. Surveys taken 6 months after the intervention suggested that many clients maintained some behavioral changes and remembered an enduring campaign message. Although these results may be somewhat overstated, considering that they are based on self-reports, they are nonetheless encouraging. Even though the African American urban salon environment appears to be conducive to rendering health advice, characteristics of the industry present challenges. Many stylists work part-time and have other jobs. Because real estate is often inexpensive and plentiful in large cities such as Detroit, salon owners tend to change locations frequently, sometimes moving in the middle of a campaign. Other shops struggle and close before the campaign concludes. Stylists experience some of the same stresses in their lives as do their African American clients, and these have consequences for the program. As a result, 23% of trained stylists fail to complete the campaign.

The advantages of salon-based programming, nonetheless, outweigh the disadvantages. Data gathered in focus groups during campaign development revealed that clients regarded their stylists as trusted advisors, had known them for an average of 8 years, and patronized their shops at least biweekly for an average of 90 minutes at a time. Client comments gathered in 6-month follow-up surveys attest to the comfort level and receptivity many clients have for receiving health information in salons. Considering the many positive aspects of the Healthy Hair campaigns, we have some lessons learned to share after several years of campaign experience:

Recruitment. Personal outreach by program staff and multipart marketing that included direct mail, peer-to-peer recruitment, and media blitzes were invaluable in recruiting stylists. The role that financial incentives ($50 stipend for training, $4 per client Chat Form) play in attracting stylists is untested. We know anecdotally that many stylists were drawn to the campaign because of personal experience — either their own or a loved one's — with diabetes, hypertension, or kidney disease.

Morale. Mid-campaign luncheons with participating stylists were an effective remedy for lagging commitment and seemed to help in troubleshooting issues that stylists were not otherwise presenting to staff. Occasional gatherings of stylists to foster a shared commitment to improving the African American community through the Healthy Hair campaign also proved helpful.

Quality. Client phone surveys conducted 6 months after the campaign revealed a few instances of potential deception by stylists. The financial rewards combined with the complexity of the intervention may have compelled a few stylists to take shortcuts in their approach or, worse, to exploit the campaign. To help mitigate this problem, we stressed quality during training. We also included a modeled Health Chat and one-on-one practice time to emphasize not rushing through the Health Chat. Staff also made salon visits within 1 week of training to observe Health Chat techniques and to correct problems. Monitoring by staff and discussion during training about creating a system for managing client recruitment, Chat Form storage, second-month re-approach, and incentive awards were also useful ways to help maintain quality.

Support. Diverse, active, and committed groups of local partners that provided structural support for the campaign were essential. Partners can include voluntary health agencies, hospitals, primary care centers, public health departments, and civic and church groups. Ways in which they can assist include providing volunteer trainers, free training space, educational brochures, cookbooks, videos, incentives, and marketing aid. Some Healthy Hair partners even provided nurses to conduct occasional blood pressure checks in salons. Others promoted the program in their corporate newsletters or featured campaign promotions in their employee cafeteria. We shared campaign results with partners along with information on how to apply local resources to improve behavior outcomes. The identification of local partners with the campaign's mission and success may well ensure long-term sustainability.

The Healthy Hair campaign develops community health resources that will last indefinitely while sustaining existing assets. The campaign turns salons into health information centers where owners and stylists provide knowledge that will stay in the community regardless of the long-term welfare of the campaign. During 2000 through 2005, each participating stylist reached an average of 31 clients, for a total of more than 14,000. Those clients, on average, talked to another three people about what they learned. This ripple effect, coupled with the success in behavior change generated from the Healthy Hair Starts with a Healthy Body campaign, demonstrates the usefulness of reaching at-risk populations through hair salons.