Thomas K. Houston, MD, MPH; Jeroan J. Allison, MD, MSc; Marc Sussman, MHA; Wendy Horn, PhD; Cheryl L. Holt, PhD; John Trobaugh, MFA; Maribel Salas, MD, PhD; Maria Pisu, PhD; Yendelela L. Cuffee, MPH; Damien Larkin, MA; Sharina D. Person, PhD; Bruce Barton, PhD; Catarina I. Kiefe, PhD, MD; Sandral Hullett, MD, MPH
Houston TK, Allison JJ, Sussman M, Horn W, Holt CL, Trobaugh J, et al. Culturally Appropriate Storytelling to Improve Blood Pressure: A Randomized Trial. Ann Intern Med. 2011;154:77-84. doi: 10.7326/0003-4819-154-2-201101180-00004
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Published: Ann Intern Med. 2011;154(2):77-84.
This article has been corrected. For original version, click "Original Version (PDF)" in column 2.
Storytelling is emerging as a powerful tool for health promotion in vulnerable populations. However, these interventions remain largely untested in rigorous studies.
To test an interactive storytelling intervention involving DVDs.
Randomized, controlled trial in which comparison patients received an attention control DVD. Separate random assignments were performed for patients with controlled or uncontrolled hypertension. (ClinicalTrials.gov registration number: NCT00875225)
An inner-city safety-net clinic in the southern United States.
230 African Americans with hypertension.
3 DVDs that contained patient stories. Storytellers were drawn from the patient population.
The outcomes were differential change in blood pressure for patients in the intervention versus the comparison group at baseline, 3 months, and 6 to 9 months.
299 African American patients were randomly assigned between December 2007 and May 2008 and 76.9% were retained throughout the study. Most patients (71.4%) were women, and the mean age was 53.7 years. Baseline mean systolic and diastolic pressures were similar in both groups. Among patients with baseline uncontrolled hypertension, reduction favored the intervention group at 3 months for both systolic (11.21 mm Hg [95% CI, 2.51 to 19.9 mm Hg]; P = 0.012) and diastolic (6.43 mm Hg [CI, 1.49 to 11.45 mm Hg]; P = 0.012) blood pressures. Patients with baseline controlled hypertension did not significantly differ over time between study groups. Blood pressure subsequently increased for both groups, but between-group differences remained relatively constant.
This was a single-site study with 23% loss to follow-up and only 6 months of follow-up.
The storytelling intervention produced substantial and significant improvements in blood pressure for patients with baseline uncontrolled hypertension.
Finding Answers: Disparities Research for Change, a national program of the Robert Wood Johnson Foundation.
Appropriate management of hypertension reduces adverse health outcomes, but many patients do not adhere to treatment. A lack of understanding of the long-term consequences of this asymptomatic condition may contribute to poor adherence.
This randomized, controlled trial assigned 299 African Americans with hypertension to receive usual care or view 3 videos that presented stories of real patients with hypertension. Among patients who had uncontrolled hypertension at baseline, those assigned to view the stories had better blood pressure control than those assigned to usual care.
Storytelling can be an effective way to teach patients about hypertension and improve blood pressure control.
Left. Unadjusted data points and model fit curves for systolic and diastolic blood pressures in the intervention and control groups over time. Middle. Smoothed model fit curves for systolic and diastolic blood pressure point estimates and 95% CIs (shaded areas) from random-effects models that compared both groups over time. Curves are displayed on a truncated scale of blood pressure to provide detail. Right. Estimated differences for point estimates and 95% CIs from group–time interactions in random-effects models that compared both groups over time. Negative deflection favors the intervention group, and the nonoverlap of the 95% CI (shaded area) with the zero difference line (dashed line) indicates statistical significance.
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Appendix Table 3.
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Story 1: Dedria - Houston : Researchers developed an interactive DVD that allowed patients to browse other patients' stories and select desired content. Presented here are excerpts from the DVD stories, which were each 4-8 minutes in length. Users could navigate to a set of "learn more" brief expert presentations on topics such as diet and exercise.
Story 2: Herman - Houston : Researchers developed an interactive DVD that allowed patients to browse other patients' stories and select desired content. Presented here are excerpts from the DVD stories, which were each 4-8 minutes in length. Users could navigate to a set of "learn more" brief expert presentations on topics such as diet and exercise.
Story 3: Julia - Houston : Researchers developed an interactive DVD that allowed patients to browse other patients' stories and select desired content. Presented here are excerpts from the DVD stories, which were each 4-8 minutes in length. Users could navigate to a set of "learn more" brief expert presentations on topics such as diet and exercise.
Albert Einstein Healthcare Network, Philadelphia, PA
January 21, 2011
Role of the principle of positive deviance.
To the Editor: I found the article by Houston et al. (1) to be quite interesting. I feel certain that the use of storytellers from the patient population was critical to the success of this intervention. What was missing from the article, and what I think the success of the intervention can be attributed to, was the role of the principle of positive deviance.
The concept of positive deviance has been defined as follows: "In every community there are certain individuals or groups (the positive deviants) whose uncommon but successful behaviors or strategies enable them to find better solutions to a problem than their peers. These individuals or groups have access to exactly the same resources and face the same challenges and obstacles as their peers (2)." In other words, we don't need to discover new approaches to help patients deal with their chronic diseases. Somewhere out there are already are people who have somehow figured things out for themselves and are achieving better results. It is up to us as a healthcare community to help our patients discover these practices and facilitate their application to their own circumstances. The positive deviance approach has been successfully applied to childhood malnutrition (3), hand hygiene (4), and, in my institution, MRSA transmission (5).
I believe the storytellers represented positive deviants in the community. Whether it be through videos, dialogues, social networking, or any other means, the more we help to connect the positive deviants with the broader patient population, the more self-discovery of the positive deviant can occur by the very people whose behaviors need to change.
1. Houston TK, Allison JJ, Sussman M, Horn W, et al. Culturally appropriate storytelling to improve blood pressure. Ann Intern Med 2011;154:77-84.
3. Marsh DR, Schroeder DG, Dearden KA, Sternin J, Sternin M. The power of positive deviance. BMJ 2004;329:1177-1179.
4. Marra AR, Guastelli LR, de Ara?jo CMP, et al. Positive deviance: a new strategy for improving hand hygiene compliance. Infect Control Hosp Epidemiol 2010;31:12-20.
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