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Thinking Outside the Traditional Box for Delivering Health-Literacy Interventions to Underserved Populations

Health-literacy interventions traditionally focus on providing individuals with health information in multiple languages; using plain, nontechnical language (i.e., language at an eighth-grade level or below); and adding visuals to health-related information to make it easy to understand and apply to everyday situations. But what can you do to reach your service population when they are dispersed in a remote geographic area or rarely congregate in a central location? And what if a reduced budget does not allow you to interact with people one-on-one? And what if the individuals you are trying to reach have limited access to media or the Internet? This article summarizes practical strategies that have been developed and used by public-health educators around the country to address these types of challenges when working with traditionally underserved, difficult-to-reach, low-health-literate populations. The key lessons were informed by a review of the literature and key informant interviews with health-intervention implementers who responded to requests for information.

Low health literacy continues to be a major barrier to care in the United States, which negatively impacts health outcomes and disproportionately affects racial and ethnic minority populations.1 Some populations have unique characteristics that can make them more difficult to reach and make their health behaviors harder to influence. Characteristics such as low or no English-language literacy, social and geographic isolation, and limited access to media and the Internet are some of the barriers that can impact the effectiveness of a health-literacy intervention. The following strategies were developed and implemented by public-health practitioners and nutrition and health educators who faced serious challenges in delivering health-literacy programs in various communities throughout the country. These strategies reflect their “outside the box” thinking as they worked creatively to implement their interventions.

Strategies for reaching geographically dispersed, rural populations. A community-based organization used a free local newspaper to reach individuals working on ranches in New Mexico. Fototabloids use photographs of racially and ethnically appropriate characters to deliver key health messages. Each comic-book-style leaflet tells a dramatic story that illustrates the characters’ experiences with a health condition, using realistic dialogue (placed in call-out boxes) to relay the key steps the characters take to address that health concern. Taking a different but equally innovative approach, an organization that delivers health services to temporary farmhands in South Carolina used dramatic storytelling and theater to deliver crucial health messages. The messages were reinforced with trivia games and interactive discussions that took place at housing camps during dinnertime and on Sundays. Another organization used a train-the-trainer model to teach adults with low health literacy to find credible health information online. This was accomplished by first training high-school students (who were easier to identify and reach) and then having them train their elders, who were less experienced at conducting online searches. Students were also encouraged to volunteer to train other adults in the community at public libraries and other common gathering places for community members.

Delivering content to those with limited English proficiency. An organization in Spokane, Washington, developed animated educational videos to deliver health information to an American Indian and Alaskan Native (AI/AN) population with very low levels of health literacy. They combined music, cartoon characters, recorded voices from community members, and backgrounds that resembled their target community to deliver culturally sensitive and age-appropriate health information. An organization in Denver, Colorado, that serves multiple recent-immigrant groups developed a strategy of recruiting, training, and employing health navigators from within each group. This model replaced the existing practice of having to first learn about each of the groups before translating, adapting, and piloting test health-outreach and education materials. Group-specific health navigators effectively tailor health messages, connect community members with services, reduce linguistic barriers, and provide information in a culturally appropriate manner. The added value of this strategy is that it provides employment to members of the recently arrived groups.

Delivering age-appropriate information to children and the elderly. An organization that provides prevention services to a predominantly young Hispanic/Latinx population produced videos to promote healthy behaviors. The videos included dramatic stories of a teenage couple that struggles with life choices related to substance abuse, sexual risk, interpersonal violence, and family conflicts. This webnovela (soap-opera-style video) was distributed via social media, YouTube, program websites, and blog pages. Another organization developed a bingo game for older adults to reinforce nutrition information in a fun and engaging manner. To deliver health information to children, an organization delivered key health messages through a series of interactive games. In one instance, good handwashing practices were demonstrated by applying a dye to the children’s hands that could only be seen with a black light and could only be removed by vigorous washing.

Conclusion

These strategies were all developed out of an urgent need to overcome specific challenges to delivering health-literacy interventions to underserved communities. Although these practices have not been evaluated, they do offer key lessons that should be considered when designing health-literacy and other health interventions for hard-to-reach individuals with low health literacy.

  1. Make the delivery of information fun and engaging. Delivering health content using theater and games can help keep participants engaged. Games and improvisation can also serve as mechanisms to reinforce the information. Content should be delivered by first relaying the consequences of specific behaviors like poor hygiene or not enrolling in health insurance and then providing procedural steps that can be taken to correct the behavior. Once the health information has been delivered, interactive games or improvised scenes provide participants with opportunities to recall and apply the information.
  2. Get to know the community. Many of the challenges experienced by health-literacy-intervention developers were addressed by acquiring an in-depth knowledge of the community receiving the intervention. Knowing where community members congregate, where they feel comfortable, and whom they trust are important considerations. Intervention developers must learn about existing community efforts to address specific health issues, especially which approaches have worked or not worked to avoid repeating mistakes. Focusing on previously successful strategies might create opportunities to form partnerships or leverage resources. This process should include engaging with local experts and respected members of the community and hiring from within the community.
  3. Think beyond language in cultural competence. Translating materials into multiple languages is necessary but not sufficient for communicating with people in a culturally competent manner. Authenticity, the format of the communication vehicle, and the values of the target group should be considered when creating culturally competent communications. Involving community members while piloting test intervention messages, tools, and delivery methods will increase the chances of the community truly absorbing the information.
  4. Focus on the end-game early—dissemination. To maximize the reach of an intervention, be creative in disseminating the information. For instance, a train-the-trainer model was effectively used to reduce the cost of doing outreach to adults by first training high-school students and then having those young people train the adults in the community. The use of social media, YouTube, and community newspapers greatly expanded the reach of a few low-budget interventions.
  5. Think of long-term impacts on the community beyond the intervention period. Health-literacy interventions are not finite. At some point, the project ends, and resources like training and technical-assistance activities end as well. But do the benefits to community members need to end at the same time? Implementers should think through strategies that can be adopted early on that leave behind some form of the intervention so that improvements to the health literacy of community members continue to accrue. For instance, content that was disseminated via community newspapers (like the fototabloids or the webnovelas) can be adapted to serve the objectives of future programs. Also, the animations designed to educate AI/AN populations can be replicated for all health centers that serve those populations. The practice of sustaining, adapting, and scaling these products is key to realizing significant impacts on health literacy in underserved communities.
1Health literacy is defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (Ratzan & Parker, 2000).
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