Culturally Appropriate Storytelling to Improve Blood Pressure

Intervention Title:
Culturally Appropriate Storytelling to Improve Blood Pressure – Cooper Green Mercy Hospital; Birmingham, AL

Controlling blood pressure is difficult because it requires strict adherence to a treatment plan that may include medication, dietary restrictions, exercise, and regular doctor visits. Researchers at the University of Alabama at Birmingham and Cooper Green Mercy Hospital wanted to find out if stories told in patients’ natural voices could inspire positive health change. They developed a digital video disc (DVD) intervention to promote adherence to hypertension medication and achieve blood pressure control among African American patients and then conducted a randomized, controlled clinical trial to evaluate its effectiveness.

Social and cultural barriers to hypertension management may exist for patient populations that distrust the medical establishment or primarily take health behavior cues from friends and family. Patients viewed a series of three DVDs featuring their peers: local patients sharing their own experiences of living with hypertension. The series also included educational segments on understanding blood pressure, avoiding hidden sodium, and staying fit. Patient stories were chosen for inclusion based on constructs of the Health Belief Model. Patients viewed the first DVD at the clinic and the next two in their own homes. This project suggests that storytelling may hold promise for presenting evidence-based, physician-endorsed health information using a peer-to-peer model.

A randomized, controlled clinical trial assigned 299 African Americans with hypertension to receive usual care or to view one of the DVDs approximately every three months in addition to usual care. Patients in the intervention group watched the first DVD at Cooper Green, where they received a DVD player and instructions on how to use it. They viewed the remaining DVDs in their own homes. Members of the usual care group viewed DVDs containing previously recorded health information segments taken from the Healthy Habits Action Minute, a series of brief messages featuring a well-known local doctor. Researchers examined the differential change in blood pressure for patients in the intervention versus the usual care group at baseline, 3 months, and 6 to 9 months.

Patients in the intervention group achieved better blood pressure control than the usual care group. The differences were most significant among patients with baseline uncontrolled hypertension: At 3 months, those who viewed the intervention DVD had a 11.21 mm Hg greater reduction in systolic blood pressure than the control group and a 6.43 mm Hg greater reduction in diastolic pressure. Overall, there was a
6 mm Hg difference in systolic pressure at 3 months between the intervention and control groups. Blood pressure subsequently increased for both groups, but the relative advantage for the intervention group remained until the end of follow-up. The trial showed that a storytelling intervention can produce significant improvements in blood pressure that are as good as what has been achieved historically with medications, and better than results with other behavioral interventions such as dietary advice.

Cooper Green Mercy Hospital
1515 6th Avenue South
Birmingham, AL 35233

From the experts:
“What we have done is selected patients from our regular population who have a diagnosis of hypertension and allow them to tell their stories: all the things that have affected them, how they feel about having the problem, and what they’ve done to control it. Storytelling is part of the Southern way of living, especially among the African American community. But we really hadn’t looked at telling that health story. It touched all of us just to hear the depth of the stories of the patients.”

Sandral Hullett, M.D., M.P.H.
Chief Executive Officer, Cooper Green Mercy Hospital
Principal Investigator

An inner-city, safety net health system in Birmingham, AL.

Clinical areas affected:

  • Hospital outpatient clinic

Staff involved:

  • CEO and Medical Director, Cooper Green Mercy Hospital
  • Health Services Project Administrator, Cooper Green
  • Project coordinator and assistants (for interviews and scheduling)
  • Videographer
  • Technology consultant

The project began in December 2006 and lasted for more than two years. Researchers developed the interactive DVD series during year one and conducted the clinical trial during year two. The first participants began viewing the DVDs in December 2007, with all viewings completed by the end of November 2008. Data collection and analysis continued into 2009.

Jeroan Allison, M.D., M.S.
Co-Principal Investigator
P: (508) 856-8999

Researchers first conducted 6 focus groups with African American patients drawn from the local community. On the basis of a carefully developed guide, focus group moderators solicited patients’ personal experiences with hypertension, communicating with physicians, medication adherence, diet, and exercise. Researchers reviewed the audio recordings and selected 14 patients to take part in video recorded interviews. Interview topics were based on the focus group findings and the Health Belief Model, which proposes that a person's health-related behavior depends on his or her perception of four critical areas: the severity of a potential illness; the person's susceptibility to that illness; the benefits of taking a preventive action; and the barriers to taking that action. The resulting 80 hours of video interviews were broken down into message-driven story units, which researchers then rated on the strength and clarity of their behavior-change content according to the Health Belief Model. The strongest units were compiled into a series of 3 educational DVDs.

Advice and lessons learned:

  1. Take care not to underestimate the time, effort, and resources required to develop a DVD intervention that uses real patients. Conducting focus groups, selecting patients to feature, filming interviews, and then selecting and editing the strongest and most relevant footage are time-intensive tasks. However, the results of this intervention suggest that taking time to understand the needs of the audience and targeting the DVD segments accordingly were important to its success.
  2. A storytelling intervention should be easily adaptable to other chronic conditions and cultural groups. Although this DVD series dealt with hypertension, other chronic conditions such as diabetes and high cholesterol are likely appropriate candidates for such an intervention. Also, many cultural groups have rich storytelling traditions.
  3. Consider a more intense intervention schedule and incorporate more follow-up. Having patients view the DVDs more frequently than every 3 months, and continuing the evaluation for more than 6 to 9 months, could strengthen the impact of the intervention and yield more information about its effects.

Cost/benefit estimate:
Due to the expenses involved in creating original DVDs (research, focus groups, interviews, recording, production), the project was costlier than expected. Although such a project requires more up-front costs than other interventions, a DVD can be copied and distributed at a relatively low cost once it is made—eliminating the cost of staff educators, for example.