Keywords

1 Introduction

Health literacy is key to achieving sustainability in healthcare services. The Shanghai Declaration (WHO 2017) highlighted that health literacy involves more than just providing information and health education: it also involves enabling people to gain access to, understand, and use information in a way that promotes good health and well-being for themselves, their families, and the society, thus leading to a healthier population globally.

The understanding of health literacy has developed over time (Parnell 2015). In 1998, the World Health Organization (WHO) defined health literacy as follows:

Cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health. (WHO 1998)

The definition describes health literacy at an individual level, but the term is equally important at an organisational level. Organisational health literacy may concern how easy organisations make it to navigate, understand, and use information and services (Brach et al. 2012; Brega et al. 2019; Bremer et al. 2021). Brega et al. (2019) highlight three key areas for strengthening health literacy at an organisational level: (1) communication, (2) conditions for navigating health services, and (3) individually adapted services and practice communities that offer a learning environment that promotes health literacy. A shift in the understanding of health literacy has been described. Parnell (2015) claims that health literacy is about the relationship between the skills of persons receiving care or treatment and the professionals or systems that are providing the care and treatment. In 2020, Centers for Disease Control and Prevention (CDC) presented the following definitions for personal and organisational health literacy:

“Personal health literacy is the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others”

“Organizational health literacy is the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others”

These definitions both emphasise the individuals’ ability to use health information and make “well-informed” decisions and acknowledge the organisations’ responsibility in addressing and incorporating health literacy in health services (Centers for Disease Control and Prevention (CDC) 2020).

People’s health literacy and participation in health services change over time and are contextual (Thompson 2007; Ministry of Health and Care Services 2019; Bårdsgjerde 2022; Kvangarsnes et al. 2023). Studies show that people with high health literacy are better equipped to participate in decisions about care and treatment that affect one’s life (WHO 2016b; Ministry of Health and Care Services 2019).

In order to strengthen the population’s health literacy, public health nurses and health professionals should be working with preventive and therapeutic health measures (WHO 2013a, 2023; Ministry of Health and Care Services 2019). Health education to increase health literacy worldwide is a priority for the WHO, and lack of health literacy is a global concern (WHO 2013a, 2016a; Dietscher et al. 2019). Health literacy is important in health promotion, disease prevention, adherence to treatment, and is particularly significant for people with chronic diseases (WHO 2016a; Ministry of Health and Care Services 2019; The Norwegian Directorate of Health 2020). Efforts to strengthen health literacy among the population require commitments at various levels (Brach et al. 2012; Sørensen et al. 2012, 2021; WHO 2013a).

The aim of this study is to develop a pedagogical model for building health literacy, leading to good health and well-being based on a narrative review (Baethge et al. 2019). Health literacy is a vital asset for promoting good health and well-being, corresponding to the UN Sustainability Development Goal (SDG) 3. The pedagogical model is universal, and globally relevant, serving as a supportive tool for promoting equality and quality in education which are important aspects for sustainable development. The 2030 Agenda for Sustainable Development reflects the complexity and interconnectedness of equality and quality (WHO 2017). It considers widening economic and social inequalities, rapid urbanisation, threats to the climate and the environment, burden of infectious diseases, and emerging challenges such as non-communicable diseases.

2 Design and Methods

This study employs qualitative design and is based on a narrative review (Creswell and Creswell 2018; Baethge et al. 2019). Traditionally, a narrative review is a comprehensive, critical, and objective analysis and synthesis of the current knowledge on a topic. In this study, a narrative review has been conducted to identify, map, and synthesise earlier pedagogical models, research with relevance, and the researchers’ knowledge and experiences, to develop a universal model for pedagogical work to improve health literacy (Baethge et al. 2019).

The narrative review was conducted using the steps set out by Baethge et al. (2019):

1

Justification of the study. This is carried out in the introduction.

2

Aim clearly stated. The present study aimed at developing a pedagogical model for building health literacy.

3

Description of the literature search. First, we searched for pedagogical models for planning, implementing, and evaluating education. In particular, we have further developed an established pedagogical model, the didactic relationship model (Bjørndal and Lieberg 1978). Second, we searched for literature in Oria, which is a Norwegian library database containing international books, electronic books, research articles, journals, and electronic documents. Our educational and research background was important when mapping relevant literature and research in developing the pedagogical model. Communication and health pedagogy is considered important in national strategies to increase health literacy in the population, as mentioned earlier in this chapter (WHO 2013a; Ministry of Health and Care Services 2019). Whilst conducting the literature search, we searched for research on communication, health literacy, and patient participation in health services to substantiate the model.

4

Key statements throughout the article are supported by relevant and updated references.

5

Scientific reasoning. The development of the model is based on a comprehensive literature review. The synthesis of the literature led to a universal model illuminating the complexity of health literacy. We have selected literature from various fields to shed light on the challenges and the complexity of building health literacy in health services.

6

Presentation of data. The didactic relationship model has for years been used at various levels of the Norwegian education system. We have developed this model for new areas, and combined knowledge from different fields to customise it when building health literacy is the goal of the learning process. In addition, our model is underpinned by medical and healthcare research that provides insight into the special challenges in the field of healthcare to enhance health literacy and sustainability. Theories of didactics, ethics, patients, and health professionals’ experiences of learning processes and patient participation in health services became important sources.

We labelled six categories relevant for the universal pedagogical model for good health and well-being: frame factors, content, goals, patients’ health literacy, communication, and assessment, based on the review and discussions in the research group. The labelled categories have different content in various contexts.

Finally, health professionals analyse, synthesise, and describe the categories in the model in relation to their unique situation. The model should not be used prescriptively, but as a tool for reflection in which the essentials in each pedagogical situation are considered. The research group consisted of researchers with backgrounds in pedagogical, medical, nursing, and social sciences. Knowledge from various fields was important to adapt the model to healthcare contexts.

3 Pedagogical Models

The pedagogical model is developed from the didactic relationship model (Kvangarsnes et al. 2023). The didactic relationship model was originally developed for primary schools (Bjørndal and Lieberg 1978) but has been adopted across other levels of education. Tyler’s Basic principles of curriculum and instruction (Tyler 1949) provides the backdrop for understanding the development of the didactic relationship model.

3.1 Tyler’s Basic Principles of Curriculum and Instruction

Ralph Tyler’s model deals with ways to formulate, organise, and evaluate educational objectives. Tyler (1949) and his ideas have had a major influence not only across all levels of schools but also in society at large (Martinsen 2005; Martinsen 2006). The model is based on causality, an underlying belief that an action will lead to a predictable result. Four fundamental questions for planning teaching were important in this model:

  1. 1.

    What educational objectives should the school seek to attain?

  2. 2.

    What educational experiences can be provided that are likely to achieve these objectives?

  3. 3.

    How can these educational experiences be effectively organised?

  4. 4.

    How can we determine whether these objectives are achieved? (Tyler 1949)

This model presents learning as a linear process that takes place in various stages. Criticism gradually grew against the measure/means thinking both in pedagogy and in health sciences (Stenhouse 1975; Eisner 1985; Martinsen and Wærness 1991). One counterargument was that educational actions cannot be reduced to technique and that learning is far more complex. Understanding learning in a cause/effect framework is, among other things, criticised for being too simplistic and instrumental. Teaching technology was criticised because the human dimension of teaching disappeared. Self-instructive material was criticised because the programme provided little contact between teacher and student and among the students. There was also a concern that knowledge might be reduced to fields that can be measured and controlled. Requirements for measurable knowledge may mean that attitudinal and qualitative knowledge may be given less status and emphasis (Stenhouse 1975; Eisner 1985; Kvangarsnes et al. 2023).

3.2 The Didactic Relationship Model

The development of the didactic relationship model was an attempt to create an alternative approach to the measure/means model to clarify the interaction between key factors that influence the learning situation (Bjørndal and Lieberg 1978). The model was a Norwegian contribution to create a comprehensive model for planning teaching or learning and was designed after the authors had experienced that strong goal management training did not work in practice. One of the goals of didactic relation thinking was to promote learning as a creative process. There was a desire to develop a model to give thinking and action patterns grounded in attitudes and values that could contribute to a positive and open learning process in which those involved participated and assumed responsibility for their learning (Kvangarsnes et al. 2023). The didactic relationship model consists of six didactic categories: goals, content, participant assumptions, assessment, working methods, and frame factors. All categories are equally important. There is also a logical connection between the distinct categories, which affect each other mutually. The overall objective provides direction for the educational reflections, planning, and implementation of the learning process (Bjørndal and Lieberg 1978).

4 A Pedagogical Model for Good Health and Well-Being

Based on the narrative review, we developed a pedagogical model for building health literacy and good health and well-being (Fig. 4.1). A similar model for building health literacy has been presented by the authors in a Norwegian textbook for public health nurses (Kvangarsnes et al. 2023). This model has been expanded and adapted to sustainable good health and well-being. Five features characterise this model:

  1. 1.

    The purpose of the model is to provide a comprehensive and universal pedagogical approach to plan, implement, and assess learning processes to build health literacy and sustainable health services at individual, group, population, and organisational levels.

  2. 2.

    The model consists of six pedagogical categories. We analyse and synthesise several categories in the situation and then develop and design learning processes.

  3. 3.

    The six pedagogical categories are frame factors, content, goals, patients’ health literacy, communication, and assessment. All of these are interrelated.

  4. 4.

    The model invites a systematic and comprehensive approach in educational work: each situation is unique.

  5. 5.

    The model should be understood within an ecological perspective (Sørensen et al. 2012). People gain health literacy depending on the social and the cultural contexts in which they are living. This means that a wide range of learning opportunities should be offered. Interactions within and between the various contexts will be significant. For example, cooperation between family and school will be important for a child’s learning of health literacy.

Fig. 4.1
A radial diagram lists the analysis and synthesis of the ecological perspective. Frame factors, content, goals, patients' health literacy, communication, and assessment.

A Pedagogical model for good health and well-being. (Author’s own figure. Modified from Kvangarsnes et al. 2023)

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This pedagogical model is a valuable tool in mapping important elements that are valid in learning situations when the goal is to strengthen health literacy. Health professionals need to map the content of the pedagogical categories in every unique situation and be aware of how the different categories are interrelated and impact each other. Using this model will contribute to professionalism and awareness in health professionals’ pedagogical work in various phases of the patient’s learning process. By analysing and synthesising the didactic categories as well as designing a pedagogical program for each unique situation, health professionals will ensure quality in the learning processes for the patients. This model is useful for reaching several of the sustainability goals. It can help to strengthen good health and well-being for patients (SDG 3) at the same time as being a tool for health professionals to ensure quality in work to strengthen patients’ health literacy (SDG 4). The model’s underlying idea is to liberate the patients’ resources and contribute to equity in health services (SDG 1).

Reflections related to the six pedagogical categories are explained in more detail in the following paragraphs. Since the model is relevant for preventive and therapeutic health services, we provide examples from both areas in the presentation of the pedagogical categories.

4.1 Frame Factors

Organisational structures, policy, and leadership are important frame factors for building health literacy at the macro level (Brega et al. 2019). Frame factors are concerned with the preconditions for educational work (Gundem 1998). A broad understanding of the term encompasses formal and informal preconditions. Formal preconditions in the context of a health service may include legislations, clinical guidelines and checklists, time, as well as learning materials such as physical and digital resources (Bårdsgjerde 2022). Informal preconditions can be defined as usual practice in a hospital, learning environment, routines, and customs related to promoting health literacy.

Frame factor theory has been used to conduct research in schools (Dahllöf 1967, 1998; Lundgren 1972). We argue that frame factor theory is relevant for analysing and understanding health education work. The level of health literacy of those involved in a learning process, the learning culture, and the culture of cooperation between professions are frame factors that may either promote or inhibit health education work (Kvangarsnes et al. 2023). The organisation of a health service may also prove to be relevant frame factors. At an organisational level, communication, conditions for navigating health services, and individually adapted services and practice communities offering a learning environment that promotes health literacy have proven to be significant frame factors (Brega et al. 2019).

Fragmented health services can result in a lack of continuity (Bårdsgjerde 2022) which has unfortunate consequences on the learning process. Bårdsgjerde (2022) found that frame factors in relation to how the patient pathway for acute myocardial infarction was organised, prevented continuity of information and involvement at a patient level.

Studies have highlighted the importance of creating health literate–friendly organisations aiming to strengthen patients’ health literacy and participation in treatment and care (Andersen-Hollekim et al. 2021; Tarberg et al. 2022). In a study, nephrologists suggested that patients requiring dialysis could learn how to cannulate their fistula, set up the machine, and run the dialysis session themselves (Andersen-Hollekim et al. 2021). Another example of health literate–friendly organisations is applying advanced care plans (ACP) in palliative care. Physicians considered ACP as a tool for open and good dialogue including patient and family caregiver’s future expectations and their thoughts regarding participation in treatment and care (Tarberg et al. 2022).

The right of patients and their next of kin to information and participation is embedded in legislation. It has been demonstrated that acute situations reduce the need for participation (Thompson 2007; Bårdsgjerde et al. 2019; Kvangarsnes et al. 2020). In chronic diseases, on the other hand, it is vitally important that the patient is involved in treatment decisions (Thompson 2007; Landstad et al. 2020). There is considerable variation in the need for information and participation for different patient groups and in distinct phases of a patient pathway. The WHO has promoted a person-centred approach to the patient, emphasising the importance of user involvement and equality (WHO 2013b).

4.2 Content and Goals

Health professionals are expected to consider participants’ prerequisites according to content and goals (Act related to patients’ rights 1999, last changed 2020). Different situations require various levels of information and participation, and people have a range of preferences and needs (Kvangarsnes et al. 2023). Age, earlier experience, life stage, sociocultural, and linguistic background are all examples of prerequisites that are important in educational work.

It is essential that health professionals have reliable professional knowledge. Knowledge of disease, treatment, medication, and how to prevent any infection or complications of disease or treatment is vital. For chronic diseases, it will be valuable that the patient obtains knowledge about the reference range for blood tests and other parameters, enabling them to take responsibility for observing any potential development of the disease. To reduce the mortality of non-communicable diseases, such knowledge is necessary for prevention as well as secondary prevention.

Knowledge is an important fundament for building health literacy and can be classified at distinct levels. In the 1950s, a classification system was developed for learning goals in three areas: cognitive goals (knowledge), affective goals (attitudes and values), and psychomotor goals (skills). The classification of knowledge measures developed by the American psychologist Benjamin Bloom (1956) is the most commonly used taxonomy, where knowledge is divided into six hierarchically ordered classes (Fig. 4.2).

Fig. 4.2
A pyramid of six levels. From the bottom, Reproduce knowledge, show understanding by communicating learning material, apply knowledge and understanding in specific situations, analyze connections between theory and practice, synthesize and abstract knowledge, and evaluation.

Authors’ own figure, based on Bloom’s Taxonomy (Bloom 1956)

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Assessing the level of knowledge that is desirable for each patient, group, and situation is crucial. All users/patients are different, and coping with diseases requires health-literate patients who understand the consequences of the different choices available to them. Formulating personalised goals is imperative. This requires continuous dialogue with users and their relatives. For some patients, it is important to assess blood test values or other parameters to be able to dose insulin, heart medicine, or painkillers. This necessitates that the patient or user holds the necessary knowledge about specific situations and can then apply this knowledge in practice. This requires not only a high-level of health literacy but also that the patient or user can analyse different choices in relation to their good health and well-being (Kvangarsnes et al. 2023).

At an individual level, health professionals and users need to cooperate in formulating goals. It is vital that health professionals, patients, and next of kin have realistic and coherent goals. A mutual understanding of such goals and a joint point of departure constitute beneficial conditions for positive interaction (Kvangarsnes et al. 2023). Especially in person-centred care, the change in direction from asking “What’s the matter?” to “What is important to you?” has been used in the development of coherent patient pathways. The purpose of the question is to obtain information about the patient’s preferences, needs, and wishes in relation to health services and the design of the service (Barry and Edgman-Levitan 2012; Oksavik et al. 2020). It may be beneficial to formulate both long-term and short-term goals. This can facilitate a step-by-step and personalised process.

As an example, public health nurses provide teaching and supervision in primary and secondary school on issues concerning sexual health, relationships, lifestyle, and substance abuse, which are critical issues for good health and well-being. Teaching and guidance take place both in groups and individually. These are areas that have elements of knowledge, skills, and values, and yet the topics are very personal. Age, gender, background, and health literacy have an impact on how pupils perceive supervision on such topics (Kvangarsnes et al. 2023). Many individuals may experience shame or believe that public health nurses are intervening in what is considered to be an ‘intimate zone’ (Gulbrandsen 2006). This may cause the person to withdraw and not take part in a planned session. When it comes to the development of attitudes and values, it is vitally important that the persons are engaged and involved from the planning stage. Pupils could then contribute relevant inputs to the goals and content of the teaching, the potential learning methods, and assessment(s) of the process.

4.3 Patients’ Health Literacy

Adapting the model for diverse groups requires knowledge about different life phases, functional ability, developmental stages, cultures, and clinical pathways, in addition to basic pedagogical competence (Act related to patients’ rights 1999, last changed 2020; Ministry of Health and Care Services 2019). Visual impairment, hearing, or reduced cognitive functions can be a hindrance during work which is striving to strengthen health literacy (Kvangarsnes et al. 2023). Health professionals must be familiar with various technical aids and resources that can ease communication and learning. For example, the National Library in Norway offers audiobooks, non-fiction, newspapers, and journals for people with difficulties in reading printed text and ordinary books due to disability or illness (The Norwegian Library of Talking Books and Braille (NLB) 2022).

The timing of providing information is also essential. Patients who are seriously and acutely ill may not be receptive to information and may only need brief, but precise, communication. Research has shown that, for example, the rehabilitation phase can be a good time for more involvement and building health literacy (Thompson 2007; Bårdsgjerde et al. 2019). Choosing the right time for sharing information is important to build health literacy and ensure good health and promote well-being in a sustainable way. Patients must be at a receptive stage to be able to absorb, assess, and use the information to make appropriate choices according to their health and well-being.

4.4 Communication

The word ‘communication’ comes from the Latin verb communicare which means to make common, or share. This is also the goal of health education (Kvangarsnes et al. 2023). Health professionals have a message that they wish to convey, and they hope to create a common frame of reference with an individual or a defined target group. At the same time, the user has experiences, as well as other knowledge, which they can share, which is relevant to healthcare professionals. Communication, therefore, must be a two-way process characterised by dialogue (Madssen 2007). This dialogue will assume different forms depending on the context.

Patient education is often provided in the context of groups set up for that purpose (Kvangarsnes et al. 2023). Cardiac rehabilitation is an example of patient education provided to patients with cardiovascular disease with an emphasis on physical activity through group training, patient education, and individual guidance. Research has shown that cardiac rehabilitation has a positive effect on good health and well-being and reduces risk factors for disease development through increasing health literacy (Rauch et al. 2016; Peersen et al. 2017; Valaker et al. 2017).

At an individual level, health education tends to take the form of supervision. As an example, breastfeeding supervision may help to achieve many of the SDGs such as reducing poverty, hunger, increased health education, gender equality, and sustainable consumption (UNICEF 2016). Increasing breastfeeding rates is clearly important across the globe. Public health nurses are responsible for supervising families undertaking breastfeeding: they meet the mother and the child in intimate and vulnerable situations. The mother has to have confidence in their public health nurse, which means that the mother leaves it to the nurse to give advice that is significant to the child’s health (Grimen 2009). This creates a relationship of power, where the trust-giver (mother) is dependent on the competence of the nurse giving access to other supplementary health services. Public health nurses will be dependent on the mother’s trust to gain access to knowledge from the mother that supplies the conditions for making good judgement-based decisions. Trust eases the transfer of information and knowledge. If the mother distrusts the nurse, it is likely that relevant information will be withheld. When it comes to caring for infants, this can have fatal consequences. Trust in such health supervision is fundamental to successful outcomes (Kvangarsnes et al. 2023).

Digital development is rapidly transforming the way in which the communication and healthcare information is exchanged together with the volume of information available (Pagliari 2021). This was clearly demonstrated during the outbreak of COVID-19. The use of digital tools and digitalisation has impacted society, and it affects the way we communicate, the pace at which we communicate, and the quantity of information available. This also applies to the health and care services. Digital health services require users to have digital health literacy or electronic health literacy (e-health literacy). This includes everything from searching for, finding, understanding, assessing, and applying health information from electronic sources to be able to apply the knowledge to address or solve a medical problem (Norman and Skinner 2006). E-health literacy in the population can actually create greater inequalities between patient groups in relation to skills and access to health services (Olsson et al. 2019; Kokkinakis 2022). This is an unintended consequence of well-meaning progress.

A Norwegian population survey, which was undertaken as part of The International Health Literacy Population Survey 2019–2022, shows that a substantial proportion of the population is in fact well prepared to use digital health services (The Norwegian Directorate of Health 2020). The same survey also shows that some groups in society report having weaker digital skills, especially older people over the age of 65, immigrants, people with long-term illnesses, and people with low level of education (The Norwegian Directorate of Health 2020, 2021). The concept of digital exclusion in relation to health services is a well-recognised topic in the public debate on the digitalisation of health services (Olsson et al. 2019; Kokkinakis 2022).

Another important issue to consider when addressing communication between health professionals/health organisation and patients/users is to employ language which is accessible, without professional terms that can impede its understanding. Much of the information available is characterised by bureaucratic and a very formal language, often dominated by professional terms (Ministry of Health and Care Services 2019; Hem and Nylenna 2021).

4.5 Assessment

A distinction is often made between summative and formative assessment (Lauvås and Handal 2014). Summative assessment has a control function and is conducted at the end of a process. In the health services’ domain, collecting patient-reported data is common practice. Patient-reported data is information that patients and users themselves report about their own experience related to health and well-being and how satisfied they are with treatment and health services they have encountered. The overall goal in collecting this type of data is to improve the quality of treatment provision (National Service for Medical Quality Registers 2022). Research on patient experiences in different clinical pathways will provide an important knowledge base for health professionals in their efforts to strengthen health literacy. Formative assessment takes place during a learning process. Formative assessment is the most important form of evaluation of health education because it is possible to create a personalised educational process where one can change learning methods, pace, content, and frameworks in accordance with the user’s preferences and feedback (Kvangarsnes et al. 2023).

Assessment of health education should take place both during the process as well as at the end. Everyone involved should take part: the knowledge can be used systematically for improvement. Feedback from users and next of kin can be particularly valuable (Kvangarsnes et al. 2023).

In a global and regional context, particularly, the considerable amount of data following the SDG3 is valuable for assessments of good health and well-being for all. The number of indicators has increased from 115 to 217 over the last 6 years (United Nations 2022). This database might give politicians valuable knowledge to prioritise vulnerable groups in the work to strengthen health literacy. ‘Leaving no one behind’ is an important principle in the SDG goals (United Nations 2022).

5 Pedagogical Analysis and Synthesis

The aim behind this universal pedagogical model is to provide health professionals with a model that is relevant in the planning, implementation, and assessment of health pedagogical work to build health literacy. Each situation is unique, and an educational tool that is open, not predetermined and includes significant pedagogical elements, will be valuable for health professionals.

Evidence-based practice must be the starting point for health professionals in designing teaching. Evidence-based practice requires that professional decisions are based on the best available research, along with clinical experience and patients’ preferences and needs in each situation. User knowledge and user participation in all phases of the process will be fundamental to pedagogical health work. From time to time, conflict can arise between clinical guidelines and a patient’s preferences. It may be the case that patients do not want to receive the recommended medical treatment: this, in turn, may cause ethical dilemmas for health professionals. The principle of autonomy versus beneficence creates challenges in interactions between patient and health professionals (Beauchamp and Childress 2019). Awareness of ethical dilemmas in educational work is vital when safeguarding patients’ interests.

Finally, health professionals must synthesise pedagogical categories in the learning process. This may lead to a systematic, conscious, and professionally grounded approach in planning, implementation, and assessment of the learning process. The synthesis aims to create a new understanding of the complexity of the learning process.

6 Conclusion and Implications for Practice

We have developed a pedagogical model that could be used as a universal model for supporting health professionals in planning, implementing, and assessing health education at all ages. Patients’ preferences and personal values must always be considered and given due respect. Improving health literacy in the population also calls for an ecological perspective when ensuring good health and well-being (Orkan et al. 2019).

The model can support innovation in health services by improving individual and organisational health literacy according to SDG9 (industry, innovation, and infrastructure). A common framework will provide opportunities for strengthening cooperation and communication on health literacy globally. The model has categories that are valid in all learning processes regarding health literacy. Implications for practice are as follows:

  • Individuals, social networks, organisations, communities, and population must be included in improving health literacy.

  • Schools should promote health literacy within their curricula, and in teaching and learning processes.

  • Collaboration between educational systems and health services globally is crucial.

  • The pedagogical model can be employed by students, health professionals, social personnel, teachers, health managers, and politicians in improving health literacy globally.