Health literacy is the ability to get, process, understand and apply health information and services in order to make appropriate health decisions. It involves the application of a wide range of skills, including reading, listening, numeracy, analytical, and decision-making skills, to health situations. Health literacy relies on general literacy skills, and has been described as “the bridge between literacy (and other) skills and abilities of the individual and the health context.” 
However, even people with average general literacy skills might find health information too complex or technical. Inadequate health literacy hinders adherence to prescription and treatment instructions.  Also, people with low health literacy tend to be less healthy and are less likely to utilise disease prevention services and information.  They also have higher hospitalization rates and worse health outcomes.  Poor health literacy leads to increased health care costs, thus posing an economic burden to societies. Low health literacy has been found to be a major financial drain on the U.S health care system, costing the economy between $106 billion and $238 billion annually. 
The 2012 European Health Literacy Survey identified 12 subdimensions of health literacy that refer to the competencies required for obtaining, understanding, processing, and using in health care, disease prevention and health promotion settings. These have been used as a conceptual basis to assess health literacy, and to develop interventions to address health literacy limitations.Health Literacy is the ability of an individual to obtain, process, and understand necessary health information. Low reading skills and poor English language comprehension make it challenging for the refugee to navigate in the new environment. Study shows that refugee with limited English Proficiency are more affected by the health literacy barrier than native English speakers.11
The refugees with low health literacy are less likely to understand written or verbal information from their healthcare providers, to follow medications or appointment schedules, or navigate the healthcare system to obtain medical care. Thus, leading to non-adherence to treatment. Low health literacy can have serious health consequences and puts additional demands on the healthcare system. According to the study, lack of health literacy resulted in difficulty in filling and refilling prescription medications, reading medicine labels, understanding the right dose, and taking medications at the right time12.
As the delivery of health care services becomes more patient-centred, clear communication between patients and health care providers is of utmost importance. Patients need strong health literacy skills to adequately utilize health information and services. Health workers also need health literacy skills to effectively communicate health information to patients.  Even health systems need to be health literate in order to provide easy access to health care services and information, and to empower patients to adequately utilize the range of available services.  The following principles have been offered to guide the writing and designing of health information to ensure that they are aligned with the skills and abilities of the users. 
Start planning by defining the communication objective and the target audience. Determine the needs, interests, and behaviours of the audience, as well as how best you can engage them. Also plan to involve the target audience during the development and testing phases of your production.
Clearly state your specific objectives in the title, cover illustration and introduction; avoid vague or numerous objectives. Ensure that your content is accurate and relevant, and that the main action points are summarized or repeated. Use effective translations or interpretations where necessary, and ensure that your content is relevant to the culture and demographics of the target audience. Keep the content clear, simple, and positive, and include information such as references, publication dates, and websites or phone numbers for further information.
Ensure that your writing is easy for your target audience to read and understand, by using common, everyday words. Avoid using unnecessary abbreviations and acronyms, jargons or technical terms, and abstract words. Use short sentences and paragraphs, and write with an active voice. Use numbers simply and directly; avoid complicated statistics or calculations, use whole numbers, and choose frequencies over percentages.
Organize your information in a logical way that is easy to follow. Emphasise important information by placing them at the beginning and at the end. Group information in small sections logically, and give the sections simple and explanatory headings.
Layout and Typography
Choose clear font types (e.g. Times New Roman or Arial) in easily readable sizes (preferably 12-16 point). Limit the variation of fonts, and use a mix of upper and lowercase letters. Also utilize white space by separating paragraphs with a line or two, and breaking up blocks of text with graphics. Use bulleted lists, underlining and bold to emphasise key messages. Use colour to highlight, add clarity, or differentiate sections. And direct attention to specific content with shading, boxes, or arrows.
Use engaging pictures that are attractive, easy to recognize, and which highlight your objectives. Choose action-oriented graphics that reinforce the key messages, and that reflect the culture and demographics of the target audience. Also, ensure that graphics are simple andnot too busy.
Role of Physiotherapy
Patient education is an important aspect of physiotherapy practice, particularly in the context of self-management of chronic diseases. Chronic diseases are associated with several modifiable risk factors; understanding these risk factors and effecting the necessary lifestyle changes is essential to preventing and managing chronic diseases. Patients with limited health literacy tend to have higher prevalence of health risk factors, lower participation in disease prevention activities, and poorer self-management skills. The 2012 European Health Literacy Survey found a strong association between higher health literacy and frequent physical activity. Effective communication is essential to enable patients make better and informed health care decisions. Thus, physiotherapists should ensure that they provide information to patients in ways that enable the patients to understand and use such information. Physiotherapists can help minimise the problems of low health literacy by identifying and supporting patients with low literacy through;
- Use of screening tests to aid health providers in identifying patients with low health literacy 
- Creating more readable health information 
- Provide health information cards/pamphlets to increase health literacy. 
- Use communication tools in the form of pictures, audiotapes, interactive computer programs to convey health information. 
- To compensate for poor reading skills, individuals depend on their listening skills, so the health care provider should speak clearly and slowly, avoiding medical jargon. It is essential to verify the individuals' understanding and comprehension by asking them to repeat what they have understood regarding the diagnosis and treatment. 
- Educate children and adults about health issue. 
- The Health Literacy Tool Shed is an online database of health literacy measures. The site contains information about measures, including their psychometric properties, based on a review of the peer-reviewed literature. You can learn about the range of health literacy measurement tools available and find tools that meet your needs.
- The AHRQ Health Literacy Universal Precautions Toolkit, 2nd edition, can help primary care practices reduce the complexity of health care, increase patient understanding of health information, and enhance support for patients of all health literacy levels. Health literacy universal precautions are the steps that practices take when they assume that all patients may have difficulty comprehending health information and accessing health services.
- Free online course on Health Literacy for Public Health Professionals focusing on Communication Skills.
- Free online course on Effective Communication for Healthcare Teams; Addressing Health Literacy, Limited English Proficiency and Cultural Differences.
- Have developed a range of resources for health care professionals around health literacy for the refugee population. Focus on Australia.
- The Enliven Organisational Health Literacy Self-assessment Resource aims to provide health and social service organisations with a self-assessment tool that can be used to guide and inform
their development as health literate organisations.
- Have developed a range of resources for health care professionals around health literacy for the refugee population. Focus on Canada.
- Institute of Medicine (US) Committee on Health Literacy; Nielsen-Bohlman L, Panzer AM, Kindig DA, editors. Health Literacy: A Prescription to End Confusion. Washington (DC): National Academies Press (US); 2004.
- Bennett IM, Chen J, Soroui JS, et al. The contribution of health literacy to disparities in self-rated health status and preventive health behaviors in older adults.(link is external) Annals of Family Medicine, 2009, May-Jun;7(3):204-11
- Schillinger D, Grumbach K, Piette J, et al. Association of Health Literacy With Diabetes Outcomes. Journal of the American Medical Association. 2002;288(4):475-482. doi:10.1001/jama.288.4.475.
- Vernon, J. A., Trujillo, A, Rosenbaum, S, (2007). Low health literacy: Implications for national health policy.
- NASEM Health and Medicine Division. Health Literacy: A Prescription to End Confusion - Patients. Available from: https://youtu.be/iCvQyRhpI4Q[last accessed 30/08/20]
- Coleman C., Kurtz-Rossi S., McKinney J., Pleasant A., Rootman I., Shohet L. The Calgary Charter on Health Literacy: Rationale and Core Principles for the Development of Health Literacy Curricula. 2010
- Cindy Brach, Debra Keller, Lyla M. Hernandez, Cynthia Baur, Ruth Parker, Benard Dreyer, Paul Schyve, Andrew J. Lemerise, and Dean Schillinger. Ten Attributes of Health Literate Health Care Organizations. June 2012. IOM Roundtable on Health Literacy
- Jacobson, Kara L; Parker, Ruth M. Health Literacy Principles: Guidance for Making Information Understandable, Useful, and Navigable. IOM Roundtable on Health Literacy. December 22, 2014
- Health Literacy: The Solid Facts. World Health Organisation Regional Office for Europe. 2013
- Schloman B. Information Resources Column:" Health Literacy: A Key Ingredient for Managing Personal Health.". Online Journal of Issues in Nursing. Available: www. nursingworld. org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume92004/No2May04/HealthLiteracyAKeyIngredientforManagingPersonalHealth. aspx. 2004.
- Baker DW. The meaning and the measure of health literacy. Journal of general internal medicine. 2006 Aug 1;21(8):878-83.https://pubmed.ncbi.nlm.nih.gov/16881951/
- VCH Primary Care. Health Literacy Basics for Health Professionals. Available from: http://www.youtube.com/watch?v=_8w9kdcRgsI[last accessed 30/08/20]
- Centers for Disease Control and Prevention (CDC). Dr. Rima Rudd. Available from: http://www.youtube.com/watch?v=4N8QxVkjHRY[last accessed 30/08/20]