One of the most effective ways to deal with health literacy issues is through a multi-disciplinary approach. It may seem like extra work for you initially, but if you can help build a network of support for your patients both in and out of the clinic, you will actually reduce your burden. You will also be seen as a supportive and caring doctor in the community, and this will mean that patients will prefer coming to you.

Health literacy is not an issue just for the doctor's clinic. It affects the whole community and since prevention is better than cure, we need to work on improving the entire community's health literacy rather than work on only one patient at a time.

There are myriad opportunities to improve a community's health literacy skills and just as communication requires at least two active participants, community health literacy programs also thrive on partnerships. These efforts enable literacy experts and health professionals to share ideas and resources, leverage funds and expand networks. Doctors need to step outside the four walls of their clinics and engage with the community if they hope to have a significant impact on public health. The good news is that because doctors are highly respected members of society, they will usually find it easy to do so, if they are willing to invest their time and energy.

Community development approaches

Most people, especially people with low literacy, get most of their health information through word of mouth. The information which doctors in "five star hospitals" provide is not always seen as credible, because poor patients often believe, quite justifiably, that doctors working in hospitals live in ivory towers and inhabit a world which is completely different from theirs. This is why the advice they give is usually impossible to implement in real life. (For example, a doctor may tell the mother to wash her hands before preparing food in order to prevent her child from getting repeated attacks of diarrhoea. But if her taps are dry, where will she get the water from?) Rather than view this as a barrier to effective health communications, why not approach it as an opportunity? This requires a somewhat different role for many health professionals. Rather than viewing their role as providing health information directly, they need to act as facilitators, and to work in partnership with others in the community. The best partners would be patients from the community, who are literate enough to understand what the doctor is saying, and are smart enough to translate this into terms their community members can understand.

These health literacy advocates are best drawn from the community and because they talk the local language; understand the local culture; and are aware of the everyday practical difficulties their people face, they are trusted by the community. They can help to design customised health education tools, which are intelligible and practical enough to be followed by other members of their community.

All this may require tapping into existing community networks, such as peer groups, social workers, religious gurus, and political workers. An excellent example of this is the work PUKAR (@https://pukar.org.in/) has done with using barefoot researchers to improve healthcare in a slum in Mumbai.

Participatory health education. A variety of literacy and public health programmes have enabled low-income, low-literacy individuals to actively explore health issues of concern to them. Health professionals take part, not as experts, but as one among a group of equals that includes people with various life experiences and levels of education.

There are many barriers that keep the poor - especially poor women - from using available health resources. By working together, health workers and groups of people can bring about changes in the medical system so that it becomes a resource rather than a hurdle for citizens, as they try to solve their health problems. The poor maybe illiterate, but they are thirsty for knowledge, which can help them to improve their lives and those of their children. The medical system will not change on its own, though. It will change only when people demand it, and when they offer creative ways to bring the health care that people need within the reach of all. Participatory approaches enable individuals to become more confident and identify ways in which they can gain more control of their health. They can then go on to teach what they have learned to others.

Here are some opportunities which can be explored.

A. Integrating health literacy into adult basic education

Adult educators work directly with people who face problems with health literacy. The significance of health literacy classes might be visualised as a pebble thrown into a pond. It starts with an initial splash: students learn information and acquire skills to improve their own health behaviour. Then, they share their learning in expanding circles of positive influence through family, friends, and community. Sharing information helps them to take ownership of it, thus increasing likelihood of later use.

• Ask clarifying questions in order to understand a problem better
• Locate information related to a specific health problem
• Fill out forms and ask for help in doing so
• Navigate a hospital
• Understand test reports and results
• Read and understand medication labels and prescriptions

This is an opportunity for learning to solve real life problems, and their students are much more likely to remember these lessons, because they are directly relevant and help them to solve their day-to-day difficulties.

Some adult educators may be reluctant to deal with health issues. They feel that because medical research and information evolves so rapidly, it is impossible to them to stay on top of it all, and they fear giving incorrect information to their students. However, it is not necessary that adult educators also be experts in health education. The most important approach to use for adult learners is skills-based education, which focuses on the fundamental reading, writing, math and communications skills that people need in order to manage their healthcare. A benefit to this approach is that it is transferable to other areas of daily living beyond health. Adults who are able to ask clarifying questions, navigate new buildings and environments, advocate for themselves and understand instructions can improve not only their own healthcare but their children's education as well! Adults who learn to assert themselves become politically more aware, and function better as citizens who are not afraid to speak up.

• Interact with bureaucracies and find their way around hospitals
• Better understand their rights and responsibilities as patients
• Understand and follow written and verbal instructions
• Administer medicines safely based on a prescription or the label
• Find and make sense of health information to help patients in decision-making

B. Integrating health literacy into children's education

The Robert Wood Johnson foundation, well known for funding innovative and effective health education programmes, has chosen an inspiring project on health literacy: puppet shows! The MicheLee Puppets travel the state of Florida in the United States, showing parents and children ways that help kids eat nutritious food for better health. The goal is to counter the problem of childhood obesity. An advantage with plays and puppet shows is that families watch them together, and reinforce each other's learning at home.

C. Health literacy through gaming and role-playing

Gaming is another way to involve the whole family. Games have the advantages of being engaging, interactive, fun, personalised, and accessible 24/7. They can simulate real situations without presenting any real risks. And of course, people of every age enjoy games.

Researchers at James Madison University in Virginia, USA, developed an interactive game called "Face the Case," which is an online role-playing game. Players are given "cases" or health situations involving health literacy issues, such as a cancer patient who wants to explore alternative treatments, or a person who needs home-based health care. They need to acquire necessary skills to solve the problems presented. The 30 cases in the game present various health literacy issues, all of which must be solved in order to win the game.

Games can also be used to increase empathy with others, which is an important part of improving communication between doctors and patients, and between patients and caregivers. At the Games for Health 2011 conference, Dr. Doris Rusch presented a game called "Elude", which is designed to educate people to support others with depression.

Fitwits (@https://www.fitwits.org) is a research project from Carnegie Mellon University in the US that is designed to help prevent obesity and improve health literacy simultaneously. Since 2007, Fitwits uses fun cartoon characters, the Fitwits and the Nitwits, to provide a hands-on educational experience that teaches basic health information about obesity and helps to transform unhealthy behaviours into healthy ones. Fitwits provides parents with an easy way to initiate conversations about obesity with their kids at home, and teachers can use Fitwits in the classroom to engage students in learning about their health. Finally, paediatricians can use Fitwits to lower barriers to talking about obesity and obesity-related illnesses with their patients.

D. Driving home the message through storytelling

Health information needs not only to be accurate, but enjoyable and inspirational as well. The real health literacy challenge may not be a lack of information, but rather the ability of the healthcare consumer to act on that information. Anything that can improve that ability is worth trying. Story telling is a great way of ensuring that the message sticks. Patients dealing with a diagnosis of diabetes, for example, often learn far more from hearing stories told by other diabetics than they do from information sheets, tables of foods, and sample menus that are dry and boring.

Storytelling makes problems and solutions come alive, because it's easier for listeners to relate to stories. Storytelling is a valuable tool in the quest to improve health literacy - and the good news is that all of us have lots of stories to share - we just need to learn how to do so.

E. Spreading the message in schools.

While solutions to low health literacy understandably target adult populations, primary and secondary schools are important partners in crafting long term solutions. Schools are responsible for developing lifelong learning skills, and just like schools teach students physics and calculus, they need to teach them how to remain healthy by transforming health education into health literacy education.

• A critical thinker and problem solver, who can make sound judgments for himself.
• A responsible, productive citizen who avoids behaviours such as unsafe sex, drunk driving or smoking, which place his health or that of others at risk.
• A self-directed learner, who has a basic knowledge of health promotion and disease prevention, and can grow this knowledge throughout his life.

Health literacy is as important as "teaching a man to fish" rather than just giving him a fish. Many countries have designed standards to guide schools in implementing effective health education classes. These will help today's students to gain the skills necessary to become health literate adults of the future. In this context, the National Health Education Standards (NHES) from the US can be viewed @ https://www.cdc.gov/HealthyYouth/SHER/standards/index.htm

F. Integrating the skills to teach health literacy into medical and nursing education

Health professionals may feel frustrated when confronting patients with low literacy skills because their education and training did not provide them with the tools needed to work with these patients. Research has shown that health professionals lack awareness, knowledge, and skills related to teaching health literacy, and that many best practices for effective communication with low literate patients are not routinely used by physicians (Coleman, 2011). Health professionals cite three barriers to screening for health literacy in their practices: lack of time, lack of reimbursement, and lack of expertise.

According to DeWalt et al (2010) the three best practices to improve health literacy that health professionals need to follow include:

1- Plain language: Use common words when speaking to patients
2- Slow down: Speak clearly and at a reasonable pace.
3- Teach-back: Ensure patient comprehension by asking them to teach back the information and instructions received in every encounter.

Your non-medical clinic staff can be a valuable resource in communicating with low-literacy patients, so make use of them. Many of them are fluent in the local languages and can act as a bridge between you and your patients.

G. Health Literacy in Libraries

Libraries are playing an important role in supporting efforts to improve health literacy. Margot Malachowski, a medical librarian, believes libraries are poised to play a greater role in "patient activation," or helping to motivate people to find out more about their health (Malachowski, 2011). Consumer health libraries (such as - the Health Education Library for People, (@ https://www.healthlibrary.com) can also help to empower people by providing them with the health information they need.

H. Teaching health literacy using popular television programming

In one experiment school students in the USA were shown a clip from the popular medical TV show, "ER", in which an elderly man complained of chest pains, followed by a discussion of the possible causes of chest pain. Then a second clip was shown, in which a doctor suggests that the man may be having a heart attack. This was followed by a discussion of the causes of heart attack. A third clip showed the man being diagnosed with congestive heart failure, followed by a summary of all points that had been discussed so far. Most students found the curriculum interesting, and learned a great deal from it. Integrating TV programming into school health classes can help to make them fun and easy to learn.

I. Patient support groups

Patient support groups for people living with certain conditions (e.g., diabetes, HIV/AIDS, etc.) can be extremely useful in providing a non-threatening environment in which patients can ask lots of questions and discuss their needs. These groups also help patients feel less isolated when it comes to dealing with critical health issues.

J. Creating social support networks

Remember that patients have support systems to help them deal with their daily routine - for example, housing, transportation, and childcare. These include: social service organisations; temples, churches and other religious organisations, nongovernmental organisations (NGOs), charities and workers from local political parties.

You may be able to make use of these resources to support your patients' healthcare needs by piggybacking on them. If your patients already have a local social service agency that helps them, they may be able to assist with their healthcare needs as well. You can even directly connect with these resources by simply calling and asking for their help -most are very happy to work with doctors.

One of the most effective ways to deal with health literacy issues is through a multidisciplinary approach. It may seem like extra work for you initially, but if you can help build a network of support for your patients both in and out of the clinic, you will actually reduce your burden. You will also be seen as a supportive and caring doctor in the community, and this will mean that patients will prefer coming to you.

If you want to be socially responsible and improve the living conditions of the poor patients in your community, tackling low health literacy is a great starting point. Doctors are respected members of society, and if you want to take on more responsibilities as a leader in your community, you can champion the cause of improving health literacy. You and your staff may be able to create a local team, which includes the various agencies listed above. In this way, you can share the load and provide the community reinforcement that is so important to reaching people with limited literacy skills. This also reduces the financial burden on each member of the team, which can be helpful when faced with limited resources. Just remember: health literacy is a big problem, but you don't have to tackle it alone.