The word ‘barber’ comes from the Latin word ‘barba’ meaning beard. The earliest records of barbers show that they were the foremost men of their tribe. They were the medicine men and the priests. They were also providing services for bloodletting, tooth drawing, cauterization and the tonsorial operations1. In Pakistan, barbering operations include hair cutting, face and scalp massaging, nail trimming, pedicure, manicure and shampooing/dying of hair. In addition barbers are also providing facilities for circumcision and incision /drainage of abscess especially in rural areas and urban slums2. Hairdresser is a person whose occupation is to cut or style hair in order to change or maintain a person's image. This is achieved using a combination of hair coloring, haircutting, and hair texturing techniques. Most hairdressers are professionally licensed as either hairdresser, a barb In the world of 21st century attitudes towards maintaining healthy lifestyle have drastically changed. Spread of communicable diseases has decreased in developed countries due to spread of knowledge and awareness. Pakistan is a developing country and has poor health indicators. It ranks 134th of 174 countries on the human development index of the United Nations 3. Attitudes towards maintenance of healthy lifestyle are grossly affected by knowledge, understanding and prevention of a disease. In Pakistan, over a third of the people are living in poverty and have fragile health structure; many patients cannot afford the costly treatment of diseases4. Amongst these diseases lie the Hepatitis B, Hepatitis C and HIV. The frequency of HBV infection has been on the higher side which is attributed to lack of public health facilities and public health awareness about transmission of communicable diseases5. A significant proportion of those exposed to HBV may not be aware of their HBV status and donor present any clinical illness but are a source of infection to others.

In the bustling cities and towns of Pakistan, barber shops are more than just places for grooming, they are social hubs where news is exchanged, friendships are made, and communities come together. However, these popular local establishments also pose a public health risk due the potential transmission of infectious diseases. The close contact and the use of blood grooming instruments can lead to the spread of blood borne pathogens such as hepatitis B and C, HIV, skin infections, fungal infections as well as other communicable diseases if hygiene is not maintained. Barbers play an important role in spread of diseases like Hepatitis B, hepatitis C, HIV i.e. blood-borne diseases as well as impetigo, folliculitis and herpes. HBV is 50 to 100 times more infectious  than  HIV,  yet  is  transmitted  by contact  with  blood or body fluids of an infected person in the same way as HIV 6. Razor  shaving  by  barbers  has  been identified  as  a  key  risk  factor  for  transmission of HBV and HCV. In  Pakistan,  daily  facial  shaving  and armpit  shaving  from  barbers  has  been identified  as  a  risk  factor  for  transmission  of  HBV and HCV 1-7. Enrolment of preventive measures is the best strategy against the spread of viral hepatitis. A study was done by Pakistan Health Research Council in which they checked the prevalence of hepatitis in all the provinces of Pakistan from 2007–08. In this study, almost 47000 individual were screened and the prevalence of HBsAg and anti Anti HCV were found to be 2.5% and 4.8%, respectively, with a combined infection rate of hepatitis B and C of 7.6% 8. According to this study, around 13 million Pakistani were suffering from hepatitis B and C [9]. Pakistan is a developing country with high population density and limited resources so it is hard to afford high cost of treating hepatitis and hepatitis associated with complications. Currently, the best way is to know the exact prevalence of hepatitis in the country and also the major risk and infection factors so they could be targeted specifically. The study that was done by Pakistan Medical Research Council was almost thirteen years ago so current scenario will be much different.

Objective

1. The objective of the study was to assess awareness among barbers regarding health hazards related to their profession
2. To identify professional practices linked with infection transmission

This Descriptive, Cross Sectional study was conducted in Urban & semi urban population of Tehsil Havelian, District Abbottabad. Havelian is a town in Midway between Haripur & Abbottabad. The population is 351222 and the area is semi hilly with most of the people affiliated with livestock, agriculture, government jobs and food/ catering industry It is one of the two tehsils of district Abbottabad. There are sixteen union councils in this tehsil 20. Barbers aged between 15 to 70 years. Random selection of barber shops in Tehsil Havelian, District Abbottabad. A sample size of 65 was taken in the area of Havelian, a town in Midway between Haripur & Abbottabad. Selected age group was from 15 to 70 years, without considering the educational status of barbers. Data was collected by using a semi–structured questionnaire and a check list. Data Collection The study tool was a questionnaire as per objectives of the study consisting of the variables identified and defined as above. The questionnaire was designed after which tested in another area of tehsil Havelian. After field testing, necessary amendments were made to the questionnaire before adopting a final version. A checklist was also used to take answers; questionnaire & checklist translated in Urdu to minimize the errors. Questions were asked by the investigator himself in local language to minimize observer errors. Data Compilation After completing the questionnaires, the requisite information entered into computer by using the software SPSS version 22. The same package was used to analyze the data. Based on this sample data 95% Confidence limits calculated. Results of the collected and calculated data were presented in the form of tables

A total of sixty-five barbers were included in this study from Abbottabad, Tehsil Havelian by using a pre-designed questionnaire that were filled in the shops by directly questioning & observing them. Out of 65 subjects questioned 32 (49%) were shop owners themselves while 33 (51%) were hired workers.

                Table 1.1 Designation of subjects

Out of sixty-five barbers enrolled for the study, 41.6% of them were in age range 16–25, whereas 40% were in the range of  26–40 and 18.8% were above 40 years of age.

Twenty eight percent of the participants did not obtain any formal education whereas 45% were under-matriculate and 27% were educated to matriculation and above. Upon asking the barbers whether they could transmit diseases through their profession or not; 75.4% answered yes in response, 20% didn’t know while a very few said no

Subjects were asked names of diseases that could spread through their profession. Hepatitis & AIDS was a major disease in response i.e. 40%.

Almost 19% of the subjects reported that they got information about spread of diseases from television. 20% got information from health care professionals, 17% from friends and 31% to 58.5% barbers had sterilizers in their shops while 41.5% had not.

Table 1.2. Disease Spread Identified by Barbers

63% of the barbers used sterilizer while 37% didn’t use it despite availability. New razor blades were used for every customer by 95% of the barbers.

Table 1.3 Usage of New Razor Blades

94% of the barbers reported to have antiseptics like Dettol & spirits in their shops while 6% of them had no antiseptics for disinfection of instruments as well as for cleaning of cut wounds caused by razor blades during shaving or hair-dressing

The present study was carried out to demonstrate the level of knowledge & practices prevalent among barbers regarding health hazards associated with their profession. We found out many variables that could prove essential in checking level of knowledge regarding health hazards and practices common amongst barbers in tackling those hazards. Through our study carried out in Havelian (Abbottabad) we found out that barbers were aware of spread of diseases through their profession by a majority of 75.4%. A study was conducted in Kharian city of Gujrat district in which it was found that 58% barbers denied about any health hazards associated with their profession whereas only 42% were aware of health hazards 12.This wide difference in level of awareness can be attributed to different factors in which most important is the area or locality of study, Abbottabad city being an educational center and mostly comprising of urban or semi-urban areas as compared to Kharian. Our subjects positively participated in the study and 40% (26 in number) of the barbers reported that most common diseases that could be transmitted through their profession were Hepatitis & AIDS while 17% of them also added skin diseases to the list. A study conducted on same topic in  South-Western Ethiopia demonstrated that 51% of the respondents reported  about the spread of HIV alone15 & 42% of barbers reported about HIV & Hepatitis in cross-sectional study carried out in Kharian city in 2003 12. It was found out in the study that 18.8% subjects got information about spread of diseases through television, 20% from health care professionals and 17% from friends & colleagues. A similar study was conducted in Egypt14in year 2008 in which it was noticed that 40% got information from television, 46.1% from friends & relatives and only 5.2% from health care workers. The level of awareness regarding diseases spread by barbers or their instruments our findings were almost consistent with a large-scale study done in Rawalpindi – Islamabad 19. When asked about preventive measures that barbers use to prevent the spread of disease, 27.7% reported the use of Dettol, sterilizer and new razor blades; 32.3% said they also do regular laundry of aprons in addition to use of Dettol and sterilizer. 10.8% of the subjects also highlighted the use of disposable razors while 18.5% only said they used Dettol as an antiseptic for prevention of spread of diseases. Whereas in study conducted in Gharbia district of Egypt it was noticed that 55.8% were concerned about use of antiseptics14, it is here to be noted that there were a variety of antiseptics other than Dettol which was only 5% in use by barbers. Other important disinfectants that were used included Savlon {an antiseptic spray} used by 49.1%, use of alcohol was by 37.9% barbers, povidone/iodine by 8.7% f barbers, hydrogen peroxide by 10.6%. This difference in use of so many disinfectants at a time in two different places on the sphere can be attributed to lack of knowledge amongst barbers in our country as well as low socio-economic status of barbers in the country. This can also be attributed to absence of basic municipal check & balance by regulatory authorities of concern that might implement strictly the use different antiseptics and use of advanced methods such as ultraviolet light sterilizers which is mandatory to run a barber shop in a country like Egypt.

Moving to the observations that were made inside the barber shops it was noticed that 47% of the barbers gave importance to clean working environment, almost 68% of the shops were well ventilated. 78% had their instruments clean or got them cleaned after using them on clients. They were aware of the importance of availability of sterilizer by a majority of 58.5% & 63% claimed to use the sterilizer regularly after instrument use.  The limitations of our study include a short duration of two months and a small sample size of only 65. A larger sample size and more duration for the study could have proven more beneficial for generalizing results. An important limitation in our study was that it was an outdoor project which required a lot of time dedication and allocation of funds,

hrough our study we have concluded that overall awareness among barbers regarding spread of diseases was satisfactory. Preventive methods commonly applied by the barbers were also satisfactory although they didn’t exactly know the mechanism of spread of disease or how the application of preventive strategies could stop the spread of disease. Socioeconomic conditions of many barbers were not outstanding except a very few who maintained their shops very well in order to enhance customer satisfaction. One more thing that we concluded is that many of the barbers tried to maintain their shops and salons by having good cleanliness, use of new razor blades, ventilation, use of sterilizers in competition with their fellow barbers without having adequate knowledge about spread of diseases and occupational hazards related to their profession. This overall satisfactory result was due to the fact that our study included mostly semi urban areas of the study where the customers are mostly dwellers of town area, cantonment area, university and college areas.

Conflict of interest: No conflict of interest

Funding: This was non-funded project.

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