Health Literacy at the UCSD
Student-Run Free Clinic Project
and Fellowship in Underserved
Health Care: Learnings
Ellen Beck, MD
Goal
T oday’s Goal:
T echniques and Approaches for Health
Literacy across a State
T each students, residents, fellows, and
faculty concepts and skills in health
Literacy
Community Empowerment- T each patients
concepts and skills in Health Literacy
Outline
Background
Approaches
Effectiveness
What seems to work
What we hope to study
My own background
McGill University
Working Department of Community Health-Elderly
services, education, community programs, mental
health services
Directed a clerkship for McGill in primary care and
geriatrics
My parents and my patients were my greatest
teachers
As a resident, Ran a program for the elderly in
health education—told them that rather than
teaching medical students how to take a medical
history, it seemed easier to teach the clients how
to give a medical history, they practiced “ chief
complaint, my past medical history, etc…
UCSD Student-Run
Free Clinic Project
UCSD Student-Run Free Clinic
Project
Founded in 1997
4 sites
Community Partners:
2 “social justice” churches, already
serving the underserved
2 inner city elementary schools
Free Clinic Project
2000 patients
“safety net” for the safety net, San
Diego-very limited safety net, many
fall through the cracks
No other resources
Provide continuous, comprehensive
high quality health care to people
without access to care
Population
51% Latino, 30% Caucasian, 9% AfricanAmerican,7% Asian, 4% other or not stated
25% street homeless
51% women, 49% male,
85% with chronic illness: Hypertension,
Hyperlipidemia, Diabetes, Asthma,
Depression
All do not qualify for and/or cannot afford
access to care
Core philosophy
Empowerment
Humanistic
Trans-disciplinary
Community as T eacher
T aught, modeled, and expected
throughout all activities
Empowerment
Create an environment in which the
other: individual, family, community
take charge of their life and achieve
joy and wellbeing
Esperanza Empowerment Group
Member 3 years
“When I first came to the group, I was carrying a lot, and I let
everything out. I cried a lot and since then, everybody in the
group has helped me to think, to defend myself, to move forward
without fear. Everything I hear here, I share with my family and
they also are changing. I was in the hospital recently and they
gave me a lot of support. I want this group to continue and want
to invite a lot of people so that they also can listen and learn not
to have fear and to move forward. This is my home and I want to
share it with everybody.”
Irma Empowerment group member
4 years
…Before coming to this group, I
did not know how to control my
temper and I did not know how to
speak with my children or my
husband. Now I feel like a
different person. I know how to
control my temper. I know how to
speak to my children. Now I
know how to get along with
myself better. Before, I didn’t
value myself. I didn’t take time for
myself. I feel much better about
myself. Thanks to all of
you….For me, this group is like a
family, something beautiful that
happened in my life, this
experience, this support….Ojala!
I wish I can continue to come and
to share.”
Humanistic
Rogerian person-centered approach
Empathy
Congruence: Self-awareness
Positive Regard: Respect
Community as T eacher
Transdisciplinary
All fields working together with the
patient at the center
Dispel hierarchies and existing
stereotypes and inter-professional
prejudices
“Culturally Humble”
Students/TraineesUCSD Medical Students
105 first year-complete required
elective
70 first and second year, each
quarter-elective
Some third year-continuity site and
selectives
80 fourth year four week clerkship
either in Family Medicine or
Underserved Medicine
Students learn to teach
Transdisciplinary
Pharmacy students-all first year,
many third and fourth year
Pre-dental students
Acupuncture students: Pacific College
of Oriental Medicine
Social Work Interns: San Diego
School of Social Work
Law Students: California Western
School of Law
182 Diabetic Patients
Process outcomes
Had the following test within the last year
Blood Pressure
HA1C
LDL
TG
HDL
Microalbumin
100%
99%
93%
88%
88%
80%
Marrone, L., Smith, S., Johnson, MJ, Beck, E Independent
Study Project, UCSD 2010
182 Diabetic Patients
Intermediate Outcomes
•
•
•
•
•
LDL <100 70%
LDL <130 86%
BP <130/80 46%
BP<140/90 77%
Mean HA1C 8.26%
Marrone, L., Smith, S., Johnson, MJ, Beck, E Independent Study
Project, UCSD 2010
What we do
T each the philosophy: through
examples, role modeling, weekly
reflection sessions, community
building, didactics that include topics
such as health promotion, health
education, and working with
interpreters, social resources
What we do
Medical students-first and second
year
Medical students-fourth year
Pharmacy students
Comprehensive Wellness Program
Inner City Elementary School
Children-Wellness T eachers-components of
wellness, physical and emotional, creativity,
expression, meaning
Blue Bandaid Brigade and Junior Health
Promoters( Increasing Health Literacy)
T eachers-Professional Renewal
Parents-Access to Healthcare and Education and
Classes( Increasing Health Literacy)
Environment-Gardens, Murals, Learning
environment
What we do at the Free Clinic
Project
T each Back method->>>>Pretend that you are the
doctor and I am the patient, or let’s switch roles,
and teach me what I have just taught you.
Barriers Reduction: Identify what barriers are
preventing someone from taking charge of their
life and their health, and with them, help to reduce
those barriers
Consider Social Determinants of Health
Personal prescriptions: Sources of stress and
Sources of Strength
Other factors That Affect Health
Literacy
Fear: Working with clients to address their
fears-teaching fear management tools
Trust: Being ‘trust bridges’, Helping people
build trust
Stigma: Address concepts of stigma and
how to overcome it
Knowledge: Classes, sharing knowledge,
adult education model
Time
What we do
Community Health
Promoters/Promotoras
Empowerment Group
Blue Bandaid Brigade: Youth Health
Promoters
Client health literacy
Clinician health literacy
Ethical Issues and Reflections
Promotoras
Introduce students to the clinic promotoras,
explain and value the importance of their
role
They come to the medical school to teach the
students,
They are available during clinic to help
problem solve and consult.
They co-facilitate the empowerment group.
T each principles and practice of
community partnership
At weekly on-site check-in sessions,
introduce the social worker and CEO
of one of our key partners, and
explain how we are ‘guests in their
house’.
T eaching session offered by
promotoras at university
Student perceived self-efficacy with the
underserved
pre-post first free clinic elective
N=431 medical students who took elective
between 2001-2001
.
Students' perception of self-efficacy with care of the
homeless, minority families, and women and children all
improved (all p<0.001).
Attitudes towards the care of the homeless and minority
families improved (p<0.001, p=0.0283 respectively).
Students reported an increase in interest in primary care, as
well as increased interest in working with the underserved
(both p<0.001).
Yoon, R., Johnson, M., Smith, S., Beck, E.
Independent Study Project, 2009
Fellowship in Underserved Health
Care
1-2 year Fellowship in Underserved Health Care
Medicine, then expanded to Dentistry,
Acupuncture, now Pharmacy, hopefully mental
health, law, nursing
Help direct the free clinic project and complete a
project and training
6 medical fellows, 5 were previously student
leaders at the free clinic project, now they have
returned to be the role models and clinic directors,
supervising all aspects of care
2 dental fellows
All now work with the underserved
National Faculty Development Addressing
Health Needs of the Underserved
135 faculty
30 states
25% from underrepresented minorities in
the health professions
3 areas of focus:
faculty development skills
community partnerships and programs
personal and professional renewal
Faculty Development Program
Age Range of Participants
40-49
35%
50-59
13%
60-69
4%
70+
1%
30-39
42%
20-29
5%
Faculty Development Program
Outcomes: Pre-post Change
in overall confidence in being able to
demonstrate your proficiency in the following skills
N: 40 of 49 participants of the 2003, 2005, 2006, 2007
Pre-Post Change: Mean
4.00
3.50
Overall
change
48.36%
3.00
2.50
2.00
1.50
1.00
0.50
0.00
2.62
3.73
Defining Promotora 118%
Designing a Promotora Program 123%
PROMOTORAS
5.00
4.50
4.00
3.50
3.00
2.50
2.00
1.50
1.00
0.50
0.00
Defining Promotora
Designing a promotora
program
1
2
Designing student curricula related
to underserved communities
4.50
4.05
4.00
3.50
3.00
2.54
2.50
2.00
1.50
1.00
0.50
0.00
PRE
POST
Designing a student or resident-run
free clinic project
4. 00
3 . 80
3. 50
3. 00
2 . 36
2. 50
2. 00
1. 50
1. 00
0. 50
0. 00
P RE
P OS T
Comparing Cultural Skills
Outcomes: Programs and Projects
60
Percent Increase
50
48
40
32
30
20
12
10
0
Developing an
educational
component or
experience
addressing
issues of
culture and
race
Teaching
about issues
of culture and
race
Cultural
competency
Developing occupational
health/environmental medicine
curricula
Designing a COPC project or educational
experience
Defining COPC
Designing a Community Medicine
Rotation
Designing a Needs Assessment
Developing community-oriented curricula
or programs
1.58
2.98
89
1.96
3.66
87
2.09
3.87
85
2.13
3.68
73
2.27
3.73
64
2.58
3.83
48
2.52
3.73
48
Developing an educational component or
experience addressing issues of
culture and race
2003: Outcomes after first 53
participants
7 new or improved student-run free
clinic projects
19 new student curricula
30 new resident curricula
21 PI or co-investigator for a grant
35 new leadership roles
What we have learned
Ownership
Coaching and role modeling
Orientation re philosophy and specific
expectations
T eaching students to be teachers
Showing the students that the patients and
community are truly the teachers:
On siteDirectly related to patient care
group reflection that starts and ends a
session and in class, related to patient care
What can be done at the state level
What lessons have we learned
Ownership: If the students feel directly
involved in care and education, they will
take responsibility
Involve community members in the
training, the teaching and the role modeling
Role Models, supervisors that have lived
and can teach the philosophy
Philosophy that is transmitted, practiced
and expected