While this chart lays out distinct divisions, the reality of health literacy practice is often based on a mixture of two or all three concepts. These three concepts could be seen as three levels in a health literacy continuum. Also, it is worth noting that the literature does not reflect a debate concerning the different concepts of health literacy. According to Nutbeam, the interactive health literacy model is currently the dominant one, while critical health literacy remains the exception. He believes that helping people develop confidence to act through community-based educational outreach and achieve a better understanding of the political aspects of education will be central in achieving a shift towards critical health literacy.

2.6 Partnerships between health and literacy organizations

The term health literacy implies in itself a junction, a crossing of two sectors: adult education and health. In classroom practice, joining the two appears to bring about positive outcomes. Introducing health topics in literacy classes brings out potential for effective learning and retention. Health is a subject of study that draws learners' interest and is a vehicle for teaching basic skills. It is in fact a two-way process. Language and literacy development facilitates the dialogue about health, while the topic of health simulates the motivation for literacy learning (Hohn, 1998, p.111). Adult educators report that health units enhanced skills in areas of dialogue, discussion, vocabulary building, reading, language development and critical thinking (Rudd and Moeykens, 1999). This can also apply to learning outside a typical classroom in a literacy centre, for example in a hospital or community health centre. The experience of the women's literacy classes in Alberta however underlines the challenge of introducing specific reading and writing activities while maintaining a broader perspective on the health issue (Norton and Campbell, 1998, p.13).

At the organizational level, many argue that in order to achieve more effective health education, there is a need for enhanced cooperation and closer partnerships between the education and health sectors. Nutbeam mentions the key role of overt alliances between the health and education sectors at the local, national and international levels (Nutbeam, 1999). Health centres of all kinds and education organizations such as literacy centres and community organizations should define common goals and objectives, share resources, plan together and develop joint programming in health literacy. Both have much to learn from each other and could benefit from the partnership. Appropriate curricula and methodologies for low-literate patients could be shared with health care professionals while health education content and analysis of community health challenges could be shared with educators. Research findings in health education offer insights into what could be included in health literacy curriculum.

Partnerships between the health and education sectors are also needed at the decision-making level. In Canada, this jurisdiction resides mainly with provincial/territorial governments who are responsible for health and education. Appropriate policies and funding mechanisms could support local and regional partnerships in the field. It is important to underline the benefits of health literacy for public health as it represents a way to reach out to hard-to-reach groups and to improve health among the least healthy.

2.7 The potential role of support staff

Dr. Rima Rudd from the Harvard School of Public Health, a key researcher in the field, has worked with fellow researchers to conduct a qualitative study (unpublished) on navigation, looking at the barriers people encounter as they make their way into and through medical institutions. Researchers conducted walking interviews with adult basic education learners, using a talk-aloud protocol as they walked through hospitals. Among the findings were that many of the adult learners who served as informants noted that they felt somewhat uncomfortable in the larger, fancier hospitals. They looked for friendly faces.

Several adult learners seemed to look for people 'like them' when they sought help. This meant that, in several cases, the adult learners turned to hospital cleaning staff when they needed directions. The staff people were warm and friendly but they had not been oriented to the lay out of the hospital and so could not usually offer the needed information. Many key support staff, who serve as greeters, had not been oriented to the layout of the hospital. According to Dr. Rudd, hospitals have in general neglected the potential role of support staff in providing certain types of information to patients.

In other studies, Dr. Rudd gathered stories from adult learners about their encounters with receptionists. They corroborated testimony from adult learners in many parts of Canada and the United States. Examples of these were collected and displayed on a "Learners' Wall" at the CPHA conference on Literacy and Health in May 2000 (Canadian Public Health Association, 2001, p. 10).

People described how, before they could see a doctor or nurse, they were handed forms to complete by receptionists who treated questions and requests for help with disdain. They cited responses such as: Can't you read? or I don't have time to fill out your form. The adult learners telling these stories reported feelings of anger and/or of mortification.