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A Reflection on a Community Driven, Bi-directional Health Literacy Course

The Medical University of South Carolina Health Awareness Certificate (MUSC HAC) is a medical student-run course of 8 topics related to health and wellness created for the Charleston Clemente Course. This paper describes the team’s approach and potential next steps to evaluate the efficacy of the program.


Thomas Agostini

Fellow, Medical University of South Carolina, 2022


Agostini, Thomas (1); Borad, Avi (1); Gilkes, James MD MPH (1); Young, Gabrielle (1); Ramsetty, Anita MD CCMS (2); Adams, Cristin DO MPH (2)

Institutions: (1) College of Medicine, Medical University of South Carolina, Charleston, SC (2) Department of Family Medicine, Medical University of South Carolina, SC


Background:

Health literacy has become a focus of research to help address social determinants of health and promote more positive health outcomes for patients who are routinely excluded from medical care due to systemic barriers [1]. More than one-third of Americans have limited health literacy, which exacerbates existing barriers to care by making the medication instructions, handouts, and paperwork inaccessible to the average adult [2]. While expansive research exists for patient populations, both in individual and group settings, very little research addresses health literacy on a community level [3]. Existing research on the community level suggests that community-based health literacy interventions can have positive impacts on both physical activity and nutrition [3]. While most Americans read at an eighth-grade level, many patient education materials are written above a tenth-grade level [4].


To improve health literacy, physicians and trainees have previously found success in partnering with community adult education programs to provide health literacy courses [5, 6]. Addressing health literacy is a crucial aspect of health equity work as it helps shift healthcare delivery to a patient-centered model [7]. Health literacy interventions can aim to empower patients to become knowledgeable self-advocates, especially for those who have been excluded from adequate educational opportunities due to race, ethnicity, socioeconomic status, immigration status, or other social factors.


The Clemente Course is a national organization that provides free, university-level education in the humanities to individuals who have been denied access to economic, cultural, and social opportunities to connect them with higher education. Clemente students study art and American history in the fall — followed by literature, philosophy, and writing in the spring. In addition to free tuition, they receive free meals, books, bus passes, mentoring, and refurbished computers to address some of their socioeconomic impediments to attaining educational success.

In 2015, a group of MUSC students and professors partnered with the Charleston chapter at Trident Technical College to create the inaugural MUSC Health Awareness Certificate (HAC). With eight core sessions that occur in the fall and spring semesters, the HAC course aims to improve the Clemente students’ health literacy and access to community health resources. Medical students and faculty members collaborate to develop the content for the medical students to then facilitate in-person lessons with the Clemente students.

Due to the COVID-19 pandemic, the course became dormant for three years. Upon its revival this year, the team reflected on some of the preliminary feedback collected on how the course can be improved and more accurately analyzed in the future.


Current Course Structure:

Clemente Students: The students who were enrolled in the Clemente Course were encouraged to participate in the HAC lessons that were regularly scheduled once a week. These HAC sessions were additive to their main course and completely voluntary. Students had to attend a minimum of four out of eight lessons to receive the HAC certificate at the Clemente graduation. Of the 17 students enrolled in the Charleston Clemente Course, 16 participated in at least one HAC class, and 15 completed surveys after the lessons, averaging 2.3 lessons attended per student. 11 students graduated the core Clemente curriculum, and 6 of the 11 graduates earned the Health Awareness certificate. The average age for participants was 57, and 55% of participants self-identified as Black or African American (Table 1). None of the respondents have completed a college or undergraduate degree. 93% of participants had a primary care doctor whom they had seen in the last six months, and 86% had some form of insurance (Table 1).


Course Content and Structure: Sessions included a 10-minute pre-recorded video on a particular health topic by an expert, including licensed medical physicians, epidemiologists, and medical academics that specialize in health disparities. Topics included oral health, smoking cessation, nutrition, exercise, insurance, domestic violence, when to see a doctor, and the cost of healthcare. Following the video, interprofessional healthcare students lead a group discussion. These discussions included questions to review key points from the videos, a review of relevant local resources, and time for the Clemente students to share their personal experiences with the healthcare system. The discussion questions and resources were also provided to Clemente students on paper handouts.


Feedback from Clemente Students:

Surveys given to the Clemente Students after each lesson asked about comprehension, relevancy, novelty, and their changes in healthcare engagement interest. Due to time and personnel constraints re-starting the dormant project, pre-course surveys were not collected. The Clemente students found the materials were helpful and easy to understand, and were relevant to their health, but the information presented was not new nor did it increase self-perceived healthcare engagement interest. Table 2 summarizes narrative feedback from both Clemente and medical students. Clemente student feedback was broken down into three themes – thoughts on materials, favorite part of the session, and areas for improvement in the session. Narrative feedback from the students revealed that the group discussion was their favorite part of the sessions. Medical students were asked what they took away from facilitating a session, and all of the responses highlighted the value of learning from the Clemente students’ experiences.


Reflection on Preliminary Feedback:

Survey results suggest that the current catalog of lessons did not increase interest in health or present new information, which suggests the program is not fulfilling its intended purpose. The existing lessons did not take Clemente student suggestions into account, which may highlight the importance of creating more student-driven content. It is unlikely that the current curriculum will have an impact on participant’s health literacy without self-identified relevant material that addresses personal knowledge gaps. This way, the sessions will have the potential to empower the Clemente Students to hopefully seek more health-related information. The current materials may have not been appropriately written to address literacy as they went largely unvetted for the reading level, interest to the students, and it not being overall new material presented. While students still found the materials easy to understand, it is important moving forward lessons are created with the intent of being approachable to students so they maintain adequate comprehension. Self-identified interest, topics, and novelty are crucial aspects in addressing health literacy to keep the students engaged with the sessions.


Narrative feedback from both Clemente students and medical students suggests that the group discussions were valued portions of the sessions, which may have helped improve classroom engagement with the topics and facilitators. In these discussions, students were invited to share their personal experience with a given topic and their overall interactions with the healthcare industry among those who face similar societal barriers. The medical students were able to hear directly from community members how difficult it can be to navigate the healthcare system, manage chronic conditions, and follow provider instructions that may not be accessible to their knowledge base. This project demonstrates the impact the Clemente course could have not only on community health engagement, but also on medical students understanding of healthcare barriers community members may face.


Moving Forward:

While the project aimed to assess health literacy, no pre and post-intervention analysis was conducted thus the team was not able to quantify measurable changes in health literacy. There are no known validated, repeatable health tools to assess for the efficacy of health literacy interventions. The HAC team plans to use short surveys at the beginning and end of each semester to better evaluate changes in health literacy on an individual level. Surveys for each individual lesson will still be utilized to ascertain feedback on individual sessions.


The future aim is to increase engagement and novelty for the Clemente students by creating content that community members have demonstrated interest in learning with new lessons replacing lower-scoring existing sessions. Currently, new lessons are being created based solely on suggestions from post-session surveys. These include sessions on hypertension, diabetes, vaccines, cancer screening, and advanced care planning. Pre-clinical medical students volunteered to work in groups for a given topic, giving them the opportunity to practice taking evidence-based guidelines and refocusing them for patient-centered materials. The medical student teams then reached out to a faculty member who has clinical or research experience on the given topic to review and record the material. The materials then undergo two rounds of faculty review to ensure an appropriate reading level for the Clemente students.


Given the small class size and geographic limitations, future analysis and quality improvement efforts will be limited in scope. However, the appreciation of intimate, small group discussions was apparent in the narrative feedback from both Clemente and medical students. To keep the existing benefits of the in-person small group while also aiming to assess the materials on a larger scale, the MUSC HAC team is currently working to reach more groups who want customized health literacy lessons.


Of the 17 enrolled Clemente students, 11 graduated the core program and only 6 earned the Health Awareness Certificate. The attrition rate of student participation in the HAC course was in-part due educational barriers still faced by Clemente students. Many students had to stop participating due to external factors including sporadic shift work, family obligations, personal health, and lack of transportation. In an effort to make the HAC materials more accessible to students if they cannot attend in person, the team is aiming to make the videos and discussion questions available online. This will allow students to make up the HAC curriculum on their own time.


The interactive modules and surveys will soon be available on the MUSC website, providing the opportunity to make-up lessons for Charleston Clemente students and engage adult learners across the country. This includes Clemente Courses throughout the United States and other community-based organizations in Charleston. Through intentional partnerships with adult education projects, the MUSC HAC team hopes to have an exponential impact on community health literacy over the coming years.



Table 1. Demographic breakdown of Clemente HAC program students.

Average Age

57

Ethnic Background

Black or African American 55%

White 31%

Race not listed or reported 14%

Gender Identity

Cis Men 27%

Cis Women 73%

Insurance Status

Insured 86%

Uninsured 14%

Access to Primary Care Provider (PCP)

Has a PCP 93%

Does not currently have a PCP 7%

Last visit with a PCP

Last 6 months 93%

Over a year 7%


Table 2: Narrative feedback from Clemente and medical students. Clemente student feedback was broken down into three themes – thoughts on materials, favorite part of the session, and areas for improvement in the session. Medical student responses were collected for their biggest take away from the experience

Clemente Student Narrative Feedback

Thoughts on materials and session structure.

“Lots of information”

“Good visuals”

“Prepared Presenters”

“Helping [me] understand the material”

“Everything was presented well”

Favorite part of the session.

“Open floor part of session”

“Overall discussion”

“Good discussion”

“Discussion” (twice)

“Class discussion”

Things that can be improved.

“Very good as is”

“More information”

Medical Student Narrative Feedback

Biggest take away from this experience.

“I had a great time getting out of my pre-clinical mindset and interacting with real people talking about issues that affect them far deeper than [studying].”


“I was able to gain experience with facilities community engagement related conversations to assist individuals to have resources to make informed decisions in regards to health insurance.”


“The [Clemente students] had some personal insights that enriched my perspective on affording healthcare. I learned about FQHCs. I also got to work on public speaking skills.”


“How important it is to continue doing community outreach events. The Clemente course program is an amazing opportunity for adults to learn more basic life skills. I truly enjoyed being a part of that.”


References:

1. Hersh L, Salzman B, Snyderman D. Health Literacy in Primary Care Practice. Am Fam Physician. 2015;92(2):118-124.

2. Kutner MA. The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy. Washington, DC: U.S. Department of Education, National Center for Education Statistics; 2006.

3. Taggart J, Williams A, Dennis S, et al. A systematic review of interventions in primary care to improve health literacy for chronic disease behavioral risk factors. BMC Fam Pract. 2012;13:49. Published 2012 Jun 1. doi:10.1186/1471-2296-13-49.

4. Safeer RS, Keenan J. Health literacy: the gap between physicians and patients. Am Fam Physician. 2005;72(3):463-468.

5. Faruqi N, Lloyd J, Ahmad R, Yeong LL, Harris M. Feasibility of an intervention to enhance preventive care for people with low health literacy in primary health care. Aust J Prim Health. 2015;21(3):321-326. doi:10.1071/PY14061

6. Hess J, Whelan JS. Making health literacy real: adult literacy and medical students teach each other. J Med Libr Assoc. 2009;97(3):221-224. doi:10.3163/1536-5050.97.3.012

7. Hasnain-Wynia R, Wolf MS. Promoting health care equity: is health literacy a missing link?. Health Serv Res. 2010;45(4):897-903. doi:10.1111/j.1475-6773.2010.01134.x


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