Brenda Remmes (center) talks with Sara Threatt during a meeting at the Mt. Calvaray Outreach Center, while a medical student gets ready to check her blood pressure.

Barbara Jackson used to make some mean homemade biscuits. These days she doesn’t touch them anymore. “Instead I have a sherbet push-up when I get a craving for something to eat,” said the Kershaw, South Carolina, resident.

Jackson, who has high blood pressure, has been learning how to bring her blood pressure down and adopt a healthier lifestyle. She’s done so through the efforts of a grant-funded health literacy project conducted through the USC School of Medicine’s Kershaw Primary Care Education Project.

The three-year program, funded by the J. Marion Sims Foundation, is aimed at improving the health literacy of patients in the rural community of Kershaw in southern Lancaster County. “The ability to read, understand, and act on health information and your doctor’s instructions has a tremendous impact on your health,” said Duncan Howe, Ph.D., in the Office of Clinical Research at the School of Medicine, and the grant’s principal investigator. “There is a direct correlation between a person’s health and their literacy level as well as their health literacy. Patients who struggle with understanding health information tend to miss appointments, make mistakes with medications and show up at the emergency room more often,” added Brenda Remmes, Director of Education and Research at the USC-Kershaw Project and the grant’s project manager.

The initial focus of the grant was to help patients read, understand and complete the complex application forms that low-income patients use to apply for free prescriptions provided by drug companies. Each drug company has their own form to complete, and for people who may require a number of medications and are not good readers, the process can be overwhelming. The grant staff recruited patients who had already been receiving the free medications into focus groups. The purpose of the groups was to help develop a procedure that was appropriate for the participants’ health literacy levels.

Medical Students such as Andrew Taber have played an active role with the health literacy program. Above: He monitors Mozell Harris' blood pressure.

From input received during a series of focus group meetings, the staff developed an informational brochure and video on the step-by-step process of obtaining the free medications. Several rounds of patient reviews and staff revisions were done before the final products were completed. “These instructional materials have been very helpful to patients, most of whom can now fill out the forms without assistance,” Dr. Howe noted. He added, “Some people still need assistance, but now they understand the process. They are more likely to come in a month before their three-month prescription runs out to fill out a new application so that they don’t miss taking their medications.”

Another objective of the project was to improve the readability of general health education materials distributed to patients. Additional patients were asked to participate in focus groups that targeted specific health conditions such as hypertension and diabetes. “Patients told us that they didn’t understand what was happening to their body when their blood pressure went up. They’d ask, ‘What does 140/90 mean?’” Remmes said. “We tried some different types of charts to help them understand their blood pressure and they really liked the one that related their blood pressure readings to a thermometer.” A wallet-size card was produced that shows a colored thermometer with a range of blood pressure readings on it. As the numbers rise, the colors on the thermometer change, with a 200/100 reading a bright red and anything below 120/80 in green. Lower readings are closer to a smiley face placed at the bottom of the card and higher readings approach a frowning face at the top.

As the groups met over time and discussed the causes for high blood pressure, nutrition surfaced as an area of particular interest. “They would tell us, ‘I know what foods I shouldn’t eat. I just don’t know how to put foods together that I should eat,’” Remmes said. So using the same process of trial and error, the grant staff designed a set of nutrition placemats. Using photos of food and suggested serving sizes, the placemats show practical examples of healthy meals and snacks that provide a balance of protein and carbohydrates. Another approach to nutrition is being pursued in the development of a series of short, animated videos on topics such as balanced meals and portion sizes.

Medical students have been involved throughout, most recently producing a video on how doctors can best communicate with their patients. “A lot of patients feel intimidated by their doctor’s education and won’t ask questions,” Dr. Howe said. Remmes believes that the process has been an invaluable one for the medical students, who have learned the importance of explaining information to patients in a manner they can understand. “I think it has been a huge eye opener for the students. They say over and over that the issue of health literacy has never come up before in their education,” Remmes said.
A by-product of the program is that one of the focus groups enjoyed meeting so much that the members still get together with the staff on a monthly basis. “We are doing the listening and they are doing the talking. I firmly believe that they have a lot to teach us and it’s important that we take the time to listen. As soon as the meetings turn into a lecture format, it turns cold and we lose their interest,” Remmes said.

Another by-product is the ripple effect throughout the community, such as the group that Barbara Jackson meets with every Wednesday. Each week between 10 and 25 people come together for a prayer meeting, lunch and bingo at the Mt. Calvary Outreach Center in Kershaw. The center’s two volunteer cooks have been involved with the nutrition focus groups at the USC-Kershaw Project, and the effect has been a positive one. Fatty meats are served less at the luncheons and fried foods, which were once a common staple, are rarely on the menu. Volunteer cook Anne Patterson has also modified her habits in her own kitchen, though her husband has accepted the new recipes better than some of her friends at Mt. Calvary. “I’ve been trying to get them to eat healthier, but they still want fried chicken,” she said.

Yet as Remmes reassures Patterson, change doesn’t happen overnight, and her new approach to cooking has already made a significant impact on the group. The way Remmes sees it, the potential for change is even greater. “I firmly believe that if you have ten people show up for a meeting, they are going to tell another ten people what they learned. People like Anne Patterson and Barbara Jackson can have a much greater influence on the health of their families and friends and church groups than I can,” she said.

Reprinted from Connections newsletter, May 2005

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