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.
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.