Health Literacy in Medical Curricula: A Framework Proposal Grounded in Qualitative Research

Health Literacy in Medical Curricula: A Framework Proposal Grounded in Qualitative Research | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Health Literacy in Medical Curricula: A Framework Proposal Grounded in Qualitative Research Bürge Atılgan, Tülin Çoban, Sevgi Turan, Sarp Üner, Hilal Özcebe, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6290004/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: In the qualitative study conducted within the scope of the HELEM-EU project, which was planned and implemented to integrate the health literacy (HL) education program into medical school curricula, the opinions of medical educators were obtained regarding this education program. In this article, the program framework created based on the findings of this qualitative research is presented. Methods: This study used a qualitative research method with a phenomenological design. The data were collected online through semi-structured, in-depth interviews conducted via a video conferencing platform between May 4 and June 6, 2021, with 20 faculty members from 20 different departments. Content analysis was used to analyze the data. Through content analysis, the codes emerging from the interview data were combined to identify themes, aiming to explain concepts and relationships. Results: Faculty members’ opinions and recommendations regarding the development and integration of HL programs into medical education curricula were categorized into seven themes: competencies, content, teaching methods and techniques, assessment and evaluation, program structure/location and timing, faculty preparation, and program dissemination and motivation. One of the most frequently mentioned themes is the "communicator" role that faculty members believe a HL education program should impart. It was proposed that training programs related to HL should include subjects such as communication, communication skills in difficult situations, crisis management, and the significance of HL. In the theme of teaching methods and techniques, it is seen that interactive methods and techniques are emphasized, just like measurement and evaluation methods. In the interviews, it is suggested that HL programs should be “structured education programs”, a vertical program should be created and they should be included in continuous professional development activities. Conclusion: Based on the qualitative findings, the HL educational programs that will be integrated into the medical school curriculum within the framework of the proposed program will increase the knowledge, attitudes and skills of the students towards different levels of HL. Consequently, it is anticipated that these programs will contribute to improving the community's overall health. Health literacy Curriculum Medical education Qualitative study Introduction The concept of health literacy (HL) was initially introduced by Simond in a 1974 article entitled “Health Education as Social Policy” [1]. Subsequently, in 1988, the World Health Organization (WHO) defined health literacy as “the cognitive and social skills that determine the motivation and ability of individuals to access, understand, and use information in ways that promote and maintain good health” [2]. In a subsequent analysis of definitions of health literacy in 2012, Sørensen and colleagues (2012) noted that “health literacy is related to general literacy,” and developed a definition as “the ability to access health-related information, to develop and make judgments and decisions about health issues throughout life, to protect, maintain, and improve health, and to understand and interpret health-related messages and information accurately, as well as the willingness and capacity to do so in order to enhance quality of life” [3]. HLis a broad concept encompassing the domains of literacy, adult education, and health promotion. HL, which has become a priority for health in the 21st century, given its pivotal role in enabling individuals to manage their own health. Individuals with low HL levels face difficulties accessing and utilizing healthcare services, encounter challenges in comprehending health information, and consequently, are less able to make proper health decisions. This has been associated with adverse health outcomes and elevated healthcare expenditures [4–7].However, data from the United States (US) in 2022 indicates that at least 88% of adults living in the US have insufficient HL to effectively benefit from the healthcare system and support their well-being (55% have intermediate proficiency, 22% have basic proficiency, and 14% fall below basic proficiency), with only 12% have adequate health literacy[8]. In Germany, using the German Health Literacy Survey 2 (HLS-GER 2), a study conducted in 2019–2020 with a representative sample of 2,151 German-speaking residents aged 18 and over, revealed that 58.8% of participants had low HL levels, with at least one-third of the survey questions rated as “difficult” or “very difficult.” Many participants reported challenges in accessing information (48.3%), understanding information (47.7%), applying information (53.5%), and evaluating information (74.7%) [9].Similarly, in Spain, a 2023 study utilizing the European Health Literacy Survey Questionnaire Short Form (HLS19-Q12) found that 59% of participants had insufficient or problematic HL levels. The strongest determinants of HL scores were identified as education, health status, and income [10].In Türkiye, the implementation of the Health Literacy Action Plan 2022–2026 has led to notable improvements, as evidenced by a comparative evaluation of nationwide surveys conducted with 15,000 participants in 2017 and 2023. The proportion of individuals with adequate HL levels increased significantly from 31.9% in 2017 to 46.1% in 2023. Additionally, significant improvements in disease prevention and health promotion were observed, with adequate HL levels in disease prevention rising from 28.4–45.7% [11]. Evidence suggests that healthcare providers equipped with an approach to HL and communication skills can make a positive contribution to reducing barriers related to HL and improving healthcare quality and patient outcomes [12–14].However, studies have shown that healthcare providers often lack the necessary approach to HL competency to appropriately address and respond to patients' low HL issues [15,16]. The increasing complexity of healthcare delivery systems has made it even more critical to enhance the approach to HL competency of healthcare providers [17,18].The future medical profession will require a more extensiveapproach to HL capacities to empowerpatients’ autonomy, engagement, and self-management skills [7]. Although most medical students will assume healthcare professional roles post-graduation, research on the HL levels of medical students remains limited. A study conducted in China with 1,275 participants found that third-year students scored the highest, while first-year students scored the lowest on all scales. Additionally, analyses revealed that socioeconomic status and parental education levels were positively associated with HL [19].In another study in Australia, the HL profiles of 86 participants enrolled in a medical education program were assessed using the 9-domain, 44-item Health Literacy Questionnaire (HLQ). Their results were then compared with national data from the Australian Bureau of Statistics. Notably, students scored significantly lower than the general Australian population in Domain 6 (ability to actively engage with healthcare providers) and Domain 7 (ability to navigate the healthcare system) [20]. In line with these studies, a considerable number of medical educators and researchers have suggested that approach to HL education should be integrated into medical education curricula. Various programs are being developed for medical students to improve their approach to HL, and their effects are being examined through intervention studies. However, research in this area also remains limited. A study conducted in the United States involved approximately 100 second-year medical students participating in a workshop that was part of a mandatory course. The workshop comprised a review, observation and practical element focusing on three HL communication techniques: teach-back, the avoidance of medical jargon, and effective questioning. It was determined that this skill-based workshop could enhance medical students' confidence in employing HL communication practices [21].Another study was conducted in the Netherlands using a randomized controlled design. In this study, medical students (intervention group: 39; control group: 40) were assessed on their self-reported competencies (HL level, attitude, self-efficacy, and knowledge and awareness regarding patient-centered communication techniques) at baseline, after an 11-hour educational intervention, and during five- and ten-week follow-ups. The intervention group demonstrated significantly higher HL competencies, with the most remarkable improvements observed in providing clear information, shared decision-making, and self-management areas [7].Despite these endeavours, only a limited number of undergraduate or continuing medical education programs have integrated HL into their curricula [18,22–24].Coleman emphasises that one of the most significant challenges in integrating HL into existing healthcare professional curricula is the lack of clear and widely accepted guidelines to define and evaluate the content of HL curricula across healthcare professional programs [25]. An Erasmus + Strategic Partnership in Higher Education European Union Project (Development and Integration of Health Literacy Education with Innovative Methods in Medical Curricula Across Europe, HELEM-EU) was conductedin collaboration with partners from Türkiye, the Netherlands, Spain and Italy in order to contribute to meeting the need in this field and to develop and disseminate medical education programs on HL. The main aim of the project is to develop, implement, evaluate and integrate a novel HL education program into medical curricula through utilisasing of a peer learning methodology to enhance the basic undergraduate education and competencies of medical doctors [26]. One of the sub-studies undertaken in the course of developing the project was conducted in a medical faculty, which is one of the project's partners in Turkey, to examine the experiences of medical educators with regard to health literacy and their recommendations for educational programmes. The study sought answers to two research questions: “What competencies do they suggest should be developed for health literacy?” and ‘What are their suggestions for a health literacy program in terms of methodology, content and assessment and evaluation?’. The findings from this qualitative study are shared in this article, along with a framework for integrating HL education into medical curricula. Methods Research Design This study was conducted using a qualitative research method with a phenomenological design [27].The data were collected online through semi-structured, in-depth interviews conducted via a video conferencing platform, in consideration of the necessity of maintaining social distancing during the pandemic. The interviews were conducted between May 4 and June 6, 2021. Research Group The study group consisted of faculty members from three different disciplines: internal sciences, surgical sciences, and basic sciences. To ensure diversity in data collection, the maximum variation sampling method was applied to select the participants. The first level of variation was implemented by determining the disciplines. Faculty members from different disciplines and departments were selected to the extent possible. Considering the aim of reaching data saturation, interviews were conducted with 20 faculty members from 20 different departments, including 8 from internal sciences, 8 from surgical sciences, and 4 from basic sciences. The distribution of the interviewed faculty members is presented in Table 1 . Six of the faculty members participating in the interviews held the title of professor, five held the title of associate professor, five had the title of assistant professor, and four held the title of lecturer doctor. The faculty comprised 12 women and 8 men. Their ages ranged between 32 and 62 years, and their years of graduation from medical school ranged between 1987 and 2005 (16 to 34 years as of the year of the study). Data Collection Tool The study utilized a 12-question interview form developed by the researchers. After drafting the form, a pilot test was conducted with two faculty members. Since no significant changes were made to the questions following the pilot test, the interviews conducted during this phase were included in the data. Data Collection Process The research team consisted of researchers specialized in public health and medical education and experienced in qualitative research. Interviews were conducted by researchers with extensive experience in qualitative interviews (ST, HO, SU, BA), and junior researchers accompanied the interviews to gain experience in qualitative research. The interviews lasted a minimum of 30 minutes and a maximum of 77 minutes. Data Analysis Content analysis was used to analyze the data. Through content analysis, the codes emerging from the interview data were combined to identify themes, aiming to explain concepts and relationships. The data analysis was carried out independently through the following steps, with the research team convening after each step to reach a consensus: The interview audio recordings were transcribed by an experienced transcriptionist. Allresearchers reviewedthewrittentranscripts. Spelling errors and parts thatwereunclear were corrected. The data were described to establish the study’sframework. All transcripts were read independently by the researchers, and code lists were created. Subsequently, the research team discussed the individual code lists, resolving discrepancies by collaboratively refining the meanings of concepts and achieving a high level of agreement. Paragraphs were accepted as the unit of analysis. The data were divided into units of analysis. Excel program was used for coding and analysis to manage quotes and organize the data. All data were transferred into Excel in paragraphs. Four researchers independently coded the first interview transcript (117 units) using the consolidated code list. All researchers in the study group came together and discussed the code given to each paragraph together to reach a consensus. After the consensus process, the consistency among the coders was calculated. Theresearchersindependentlycodedasingletranscriptfrom the dataset, and pairwise consistency was assessed. The agreement coefficient betweenthetwocoderswiththehighestconsistencywascalculatedas0.89for95dataunits. These two coders (BA, TÇ) then divided the dataset and continued independent coding. The two coders maintained communication during their work, discussing the code list and adding new suggestions or revisions to the main code list. A common opinion was formed at each stage. After the coding was completed, the data were described based on the themes and codes, and the findings were written. The results were defined and interpreted, with participants' views presented in direct quotations using quotation marks. Any information that could reveal the participants'identities was removed from the quotations, and basic characteristics (gender, title, and participant number) were provided in parentheses at the end of each quote. Validity and reliability To ensure validity in this study, participants were selected from various disciplines and fields to provide an in-depth understanding of the research question. Diversity was incorporated to represent different experiences and perspectives. The interview forms were developed with the participation of all members of the research team who had expertise in the field. Pilot tests were conducted for the interview forms and process. During the data collection phase, care was taken to create a positive and natural interview environment to ensure the collection of high-quality data. At each stage of the research and data analysis process, the research team reviewed and discussed the progress. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used to report this study [28].Findings were presented under themes, using unbiased direct quotations. Ethical Issues The study was examined at the meeting of the Gazi University Ethics Commission held on 23.3.2021 (Number: E-77082166-604.01.02-59610) and found ethically appropriate. Faculty members were contacted by e-mail and telephone and informed about the study.Theywereaskedfortheirinformedconsenttoparticipate,andthe informed consent form was shared via e-mail. The participants' permission was also obtained for audio and video recording during the interviews. Confidentiality was ensured for recordings and analysis. The research report does not contain information directly indicating the identity of the interviewees. Limitations of the Study This research demonstrates the limitations of the interview technique in qualitative studies. The data was obtained from a semi-structured interview with the participants,whichwas based on their self-report. Although efforts were made to ensure maximum diversity in the study, the findings do not represent the situation and context of all medical faculties. By the nature of qualitative studies, the study reflects the views of the faculty members who participated. Therefore, the generalizability of the findings is limited. Results In this study, faculty members’ opinions and recommendations regarding the development and integration of health literacy programs into medical education curricula were categorized in seven themes: competencies, content, teaching methods and techniques, assessment and evaluation, program structure/location and timing, faculty preparation, and program dissemination and motivation. Each of these themes offers a comprehensive examination of the key elements essential for the development of HL programs, addressing different dimensions of medical education programs. The findings, which serve as recommendations for medical education programs, highlight the expected competencies related to health literacy for graduates, the place and scope of HL programs within medical curricula, proposed content, teaching methods and techniques, assessment and evaluation methods, as well as faculty preparation and motivation. Examples of quotations related to the themes summarized in this section can be found in Appendix. Recommendations for HL and Its Structuring within Medical Education Programs 1. Competencies In the study, the participants were invited to share their insights on the identification of competencies in the programs intended for the development of health literacy. The participants were asked to express their views on the essential characteristics that should be exhibited by physicians who demonstrate an understanding of health literacy and are able to conduct effective patient-physician interviews for this purpose. The suggestions developed were identified and summarised under the theme of competencies for health literacy. It was observed that the role of "communicator" emerged as one of the most frequently mentioned themes. The recurrence of this theme underscores the significance of "effective communication" as a fundamental competency in fostering a patient-physician collaboration based on HL. To be able to interview applicants/patients with varying levels of HL requires managing difficult situations, determining communication methods according to changing contexts and applicants, and restructuring processes.Consequently, it is important to focus on the development of existing communication skills programs and to ensure that communication skills include communication with both patients and colleagues in the development or integration of HL for medical education programs. The fact that issues such as being an expert in the field, following and implementing the most up-to-date evidence-based diagnosis and treatment processes are among the frequently emphasized issues shows that health professionals need adequate field knowledge and continuous learning and self-improvement skills. While continuous learning and development constitute a pivotal aspect of medicine, it is a more significant and prioritised domain for the implementation of HL skills. In addition, the importance of transferring the information to the community and the individual in health service delivery, taking into account their characteristics, needs and expectations, by creating or using appropriate materials is emphasized. The frequent mention of elements such as adherence to ethical principles, integrity and honesty emphasizes the importance of a professional understanding based on trust. It is seen that skills such as respect for differences, caring for the patient, honesty and transparency, and emotion management should not be neglected in terms of HL. These findings suggest that competencies such as communicator, expert/scientific, educator/informant, and adopting ethical values are indispensable for HL programs. It is also recommended that health professionals possess teamwork and leadership skills, a willingness to self-evaluate and seek continuous improvement, familiarity with the community they serve, the ability to advocate for health issues, effective time management, and the capacity to assess health literacy levels. 2. Content It was proposed that training programs related to HL should include subjects such as communication, communication skills in difficult situations, crisis management, and the significance of HL. These recommendations indicate that medical education should encompass not only the acquisition of technical knowledge and skills but also the development of non-technical skills such as communication and stress management. Another suggested themewas assessing the HL level of the applicant and the patient. At the same time, it is suggested to enrich the scope of HL programs by incorporating the social dimension of health services and medical education from a broader perspective such as sociology, psychology, community recognition and social accountability. Another critical issue concerning HL is emphasized under the title of “management of misinformation dissemination”. Moreover, contents such as stress management, crisis management and time management were defined as being related to HL programs. 3. Teaching methods and techniques In the sub-theme of teaching methods and techniques, it is seen that learner-centered and interactive learning methods and techniques are highlighted. Within the small group methods, it is suggested to diversify active learning methods and thus create teaching environments that will provide students with experience in HL. It is emphasized to use methods such as simulations, discussion, case studies, role-playing, movie watching and field studies.These methods indicate an emphasis on providing opportunities for experiential and hands-on learning, focusing more on developing students' skills rather than relying solely on theoretical knowledge and lecture-based methods. Clinical practices also play an important role in this process, asthey aim to provide students with experience in real patient environments. In addition, it was suggested that public education and extracurricular activities provide opportunities for medical students to develop community service and social responsibility awareness. 4. Measurement and evaluation Assessment and evaluation processes play a critical role in determining student outcomes and evaluating the quality and impact of medical education. It is noteworthy that, similarto teaching methods, measurement and evaluation methods arerecommendedto focus mainly on practice and performance assessment. Performance assessment, direct observation, simulation-based assessment methods, and practical exams such as OSCE are important in evaluating how students transfer what they have learned into practice. Self-assessment and peer assessment can also be employed simultaneously at this stage. Formative assessment supports the learning process by providing students with continuous feedback. In this context, the inclusion of feedback and reflection will allow students to evaluate themselves and continuously review their progress. Onlyoneperson suggested conducting a theoretical exam for knowledge level. 5. The place and timing of HL in medical education programs In the interviews, it was emphasized that HL programs should be “structured education programs.” Regarding the timing of these programs, it is significantly stated that a vertical program should be created, with the pre-clinical period serving as the starting point and the clinical years augmenting and enriching the program. Furthermore, emphasis is placed on the continuity of the process and the significance of integration, suggesting its incorporation into both specialisation and continuous professional development activities, particularly during the post-graduation period. 6. Preparation of faculty members The preparation of faculty members is also a crucial part of this process. In particular, faculty members' role modeling, mentoring and ownership of the program were mentioned among the factors that enhance the success of training programs. Additionally, their experience in the field and communication skills also play a critical role in this process. These findings underscore that, in medical education, faculty members should not only serve as conveyors of knowledge but also role models, mentors and guides. 7. Dissemination of Training Programs Accreditation processes of medical education programs aim to maintain and improve quality standards in education. It was emphasized as an opinion that the inclusion of HL in medical education accreditation standards could contribute to the dissemination of programs and the encouragement of medical faculties. The faculty members participating in the study approached HL programs within medical education from a broad perspective.They addressed various elements of the programs, from structured training to content and methodological diversity, as well as performance-based assessment and evaluation processes. They emphasized the importance of ensuring methodological diversity and incorporating continuous feedback mechanisms through the active participation of both faculty members and students at every stage of the educational process. According to the findings of the study, the general features of the HL program framework can be summarized as follows: 1. Scope of the competency frameworks (in addition to the defined competencies for medical students) Understanding and recognizing society, developing social and cultural awareness Communicating appropriately according to the HL levels Managing the spread of misinformation Developing of teaching skills 2. Structuring the HL education program: Vertically integrated and continuous education starting at an early stage Humanities and social sciences education Elective courses Extra-curricular student group activities 3. Teaching methods and techniques Small group work, Interactive (active) learning methods Guidance from faculty members 4. Strengthening assessment and evaluation methods: Performance-based assessment methods Peer assessment and self-evaluation 5. Dissemination of programs Institutional ownership Monitoring quality through accreditation Discussion The consensus among all participants in this study was that enhancing health literacy in health professionals’ education would enhance the quality of health services and contribute to public health beyond the mere improvement of society's capacity to access information [29]. The integration of health literacy education into medical education programs was thus recommended. In alignment with the opinions of the study's participants, a program framework was developed that encompasses recommendations on the design and implementation of medical education programs. This framework encompasses competencies, content, learning-teaching methods and assessment and evaluation elements (Table 2 ). The most prominent competency area in the study was communication. All participants emphasized that communication is an essential skill that should be acquired in medical education and that effective communication with the patient, appropriate to the level of HL and free of medical terminology, positively affects treatmentcompliance. This suggestion is supported by guidelines developed and studies conducted in the field of patient-physician communication, which accept the importance of patient-physician communication appropriate to the level of HL without medical terminology as critical in patient-centred healthcare [30,31]. Participants highlight that the ability to recognize social and individual differences, respect cultural values and establish a trust-based relationship with patients by anticipating the effects of these factors on health outcomes can be gained through structured training programs. The effects of social determinants of health on individual and community health are indisputable. Identifying these effects and transferring them to patient-physician communication will contribute to establishing a trust-based relationship as well as increasing the quality of health or care processes. In this context, it is accepted that being aware of and supporting cultural and social differences in health processes should be a part of medical education [31–34]. Other competencies emphasized in the study to support this competency were recognitionof the society and health advocacy. The views included analyzing the society, foreseeing needs, suggesting change and leading the way. These competencies align with the views in the literature that health professionals should be individuals who create change, have a vision, define reasons for change, direct change, and be role models [35]. In this context, leadership has also found its place among the defined competencies. In the study, communication and having the scientific knowledge of the field stand out among the competencies defined. In today's rapidly evolving world, possessing knowledge in a specific field will remain limited without the ability for continuous development. In line with this, the views reported in the study include recommendations for health professionals to maintain and enhance their professional competencies through continuous learning and to adopt an inquisitive, investigative and critical approach to their practices. These competencies encompass accessing up-to-date information and practices, applying them in service delivery and sharing them with patients. Participants also emphasized that accurate information sharing with patients and society requires educational skills beyond communication skills.Similarly, the Institute of Medicine (2004) report highlights the importance of physicians developing teaching skills and maintaining motivation for lifelong learning to enhance the health literacy of the population [36]. The competencies emphasize two key aspects that form the foundation of the medical profession: the adoption of ethical values and respect for the profession. Adoption of ethical values enables the physician to act in accordance with patient rights, human dignity and professional responsibilities. These values are based on principles such as trust, justice, honesty, and prioritizing patient welfare[37]. Commitment to ethical values is not only a cornerstone of the quality of medical practices but also the foundation of trust-building patient-physician communication. It is crucial to address this focus in health literacy programs as well. An examination of the international and Turkish physician competency frameworks [33-40]reveals that competencies such as expertise in the field, effective communication, leadership, collaboration, professionalism and health advocacy, which are prominent in this study, exhibit significant overlap despite the use of varying expressions. In addition to the competencies aligned with the national and international frameworks, this study proposes a new competency: "identifying the level of health literacy (HL)". This competency is regarded as an essential skill for initiating patient-physician communication. In the course of the interviews, this competency was defined in different scopes for the community and the individual, and it was stated that it is one of the starting areas for the physician in planning care and service. Another competency suggestion that differs from the competency frameworks is that of being an educator. Although national and international medical education competency frameworks contain detailed competencies in the areas of communication skills and health advocacy, they are limited in meeting the competencies emphasized in this study, such as society recognition, educational role, social accountability, patient education and intercultural sensitivity. Similarly, Barnabe et al. (2023) draw attention to the fact that CanMEDS 2015, a widely accepted physician competency framework, does not include competencies for concepts such as equality, cultural safety, diversity, inclusion and social justice and argue that an update study should be conducted [41]. In this context, the National Medical Education Competencies in Türkiye (UÇEP, 2020) has a broader framework. This document employs a biopsychosocial approach, encompassing the protection and enhancement of public health, the concepts of social accountability and social obligation, and the sociodemographic and sociocultural characteristics of the individual.. However, in this document, the competencies for determining and implementing communication strategies appropriate to the social and cultural structure of the society and the individual and differences are limited or scattered in different sections of the competencies[40]. Another aspect of competency frameworks not covered in the context of our findings is the definition of the physician's role as an educator. While the concept of providing health education is mentioned in these frameworks, competencies such as developing educational skills, providing clear and understandable information, and offering education tailored to the HL level of the community have not been directly addressed. From the perspective of HL programs, these competencies stand out as distinct from others and should be considered when developing such programs. For these recommendations, it is helpful to examine the WHO-ASPHER (World Health Organization- The Association of Schools of Public Health in the European Region) European List of Core Competencies for Public Health Professionals. Although this framework is aimed at the public health workforce, it is stated that some of the core competencies are aimed at all health professionals due to the nature of public health and the differences arising from the structuring of public health services in some countries. One of the competencies in this framework is health promotion. As an umbrella concept, health promotion consists of competencies for improving, protecting and preventing diseases. In the WHO-ASPHER Framework, this competency includes education and promotion through community participation, health literacy at community, organizational and individual levels, empowerment of citizens, assessment of health needs, screening and secondary prevention, and evaluation of health promotion interventions and programs. These definitions make it necessary to look at health services beyond a disease and treatment perspective. General medical competency frameworks have this perspective to a limited extent. This perspective needs to be taken into consideration not only in HL program competencies but also in the updating of general medical competency frameworks [42]. The participants proposed including modules/courses in medical education that address the understanding and evaluation of health communication and health literacy levels. In this context, they suggested incorporating communication in difficult situations, effective communication, empathy, the prevention of misinformation dissemination, sociology and psychology for understanding people and society, the importance of HL and the evaluation of HL levels into the programme content. In medical education, communication skills are considered as the most fundamental, critically essential non-technical skills[30]. Effective communication is contingent upon first evaluating the patient's health literacy level and determining suitable communication methods, thereby enhancing compliance with health services, care and treatment [32,43].The study emphasised the imperative of incorporating subjects such as sociology and psychology into medical education programmes to cultivate competencies in comprehending society, considering social contexts, and assuming social accountability, in accordance with the extant literature [44]. Another prominent issue is the concept of misinformation dissemination. In order to ensure that people have access to the guidance they need, especially in times of crisis, the inclusion of the management of misinformation dissemination within the scope of medical education will enable physicians to improve their skills in directing society or individuals to reliable sources and raising public awareness [33].The experience during the COVID-19 pandemic has clearly demonstrated the importance of managing the spread of misinformation. Participants emphasized the importance of conducting teaching activities in interactive and small groups. Educational activities conducted in small groups contribute to the development of learners' communication skills as well as increase learning motivation and retention by ensuring that learners are active [45]. Activities such as simulations, case discussions, role play, movie discussions and field practices, which stand out in the statements within the scope of small group trainings, show that it is preferred to create learning opportunities by using problem-solving skills by doing and experiencing instead of transferring theoretical knowledge. This is in line with Kolb's (1984) Experiential Learning Theory in the context of prioritizing analyzing knowledge, learning through experience and using it in real life [46]. Simulation is a teaching technique that facilitates learning in areas such as the development of communication skills and crisis management through practice, reflection and feedback by eliminating the risks in real life experience [47,48].Roleplay, movie discussions and case discussions also help learners to recognize social and cultural contexts, develop ethical attitudes, and gain skills such as understanding the patient and empathizing [49].Practices carried out in the field provide students with the opportunity to encounter and directly interact with the community they will serve in the future while also providing them with skills to improve public health [44].Previous studies have also highlighted that, particularly in small group educational activities, instructors' comprehension of the curriculum, interest in teaching, and ability to create a positive learning environment can enhance learners' motivation and ensure the retention of knowledge [50,51].Utilizing these methods will contribute to the development of multiple competency areas, thereby increasing the effectiveness of teaching. Some participants suggested that HL programs and courses should be mandatory, while others recommended offering them as electives or through interest clubs. The opportunity for students to voluntarily and willingly participate in elective courses or interest club activities is among the emphasized advantages for fostering learning motivation. Elective courses provide students with the opportunity to engage in in-depth learning in areas of interest, develop self-directed learning skills, and enhance their motivation to learn [52]. Extracurricular voluntary activities, such as student community events and interest clubs, not only foster intrinsic motivation but also strengthen students' social bonds, enhance their professional skills, and equip them with competencies in areas like the social determinants of health, health management, and developing health-promoting policies [53,54].Programs developed in this direction can be implemented through different approaches or a combination of these, tailored to the conditions of the schools. It is expressed that measurement and evaluation throughout the process, in line with competencies, goal-oriented, learner-centered, evidence-based, systematic and transparent methods will motivate learning. Self-assessment, peer assessment, reflection, simulation-based and OSCE are among the measurement methods emphasized. Epstein (2007) emphasizes that multi-process-oriented methods designed to measure competencies not only assess skills such as communication, clinical decision-making, and problem-solving but also foster lifelong learning motivation [55].Peer and self-assessment methods, which are also prominent in the study, enable learners to take responsibility for their learning, become aware of their strengths and weaknesses, and gain the habit of receiving and giving feedback [56].Shumway and Harden (2003) state that self- and peer-assessment are used in the evaluation of attitudes and communication skills in the field of medical education [57].Simulation-based and objective structured clinical exams, developed according to educational objectives, allow the measurement of clinical skills, interpersonal behaviors, and communication skills in realistic and safe environments, while also providing learners with feedback to support their development [55].In summary, as with teaching methods, it is emphasized that assessment tools should be designed to be goal-oriented, focused on skill development, performance-based, and applied, ensuring that feedback is provided not only on outcomes but also throughout the process. The place and timing of the HL programs in the curriculum are important. The most frequently emphasized recommendation in the study is the implementation of structured vertical programs starting early in undergraduate education, from the first years, with increasing intensity through clinical and postgraduate phases, and extending to continuous professional development programs. The Institute of Medicine (2004) report also recommends that trainings aimed at developing HL skills should be integrated in a way that provides reinforcement in the clinical period [36].Studies on developing HL programs for health professionals and evaluating their effectiveness are limited. In a study conducted with family medicine residents, 12 first-year family medicine residents participated in four HL trainings over 11 months, and pre-post assessments were conducted. The participants' knowledge levels showed significant improvement immediately after the training. In communication skills, only two (asking open-ended questions and checking understanding) showed permanent improvement at the 11-month follow-up, and the other six behaviors, although progress was made during the training, were not maintained in the long term. The results of the study show that information is quickly learned but that it is challenging to integrate skills into clinical practice [23].As these studies also reveal, this vertical integration needs to be ensured in order to reinforce and develop competencies. A review study on HL training programs for health professionals identified 26 articles on HL training and 27 on HL-related communication. Most studies were non-randomized, longitudinal, and used pre-post evaluations. A total of 35 studies incorporated both didactic and experiential teaching methods, with experiential techniques including role-playing (n = 23) and workshops (n = 15). Regarding HL-specific interventions, all 26 studies included educational content, while 16 featured written and oral examples of best practices, 13 provided a general HL overview, and five focused on self-management and empowerment. HL-related communication skills interventions covered various strategies such as the “teach-back” method, avoiding jargon, summarizing information, asking open-ended questions, and teaching shared decision-making. Most studies did not report barriers to implementing HL knowledge and skills (n = 45) or information about the facilitators (n = 52). Reported barriers included difficulties in applying learning, behavioral changes, overcoming habits, overestimating competencies, adapting training to daily practice, sustainability concerns, and resource limitations. Other challenges included individual pressures to use technical language and organizational obstacles, such as a lack of faculty role models, time constraints, and competing clinical priorities. And, facilitators included institutional commitment, leadership and administrative support, HL advocates within the organization, and an institutional focus on HL [58].The study emphasized the need for innovative teaching and assessment methods to enhance performance, rather than relying solely on didactic instruction and knowledge transfer. Institutional and faculty preparedness are crucial for the success and implementation of programs. In the study, opinions on the contribution of faculty members' preparation, their experiences in getting to know the society and maintaining appropriate communication, mentoring and role modelling for students, and their motivation to create an environment that supports learning goals to the effectiveness and sustainability of HL programs came to the fore. The study thus posits that a participatory approach during the programme development process, in conjunction with the implementation of an effective communication strategy during the dissemination phase, is a prerequisite for the preparation of institutions, faculty members, and students for the application of these programmes. A further recommendation from the study is the integration of these programmes into accreditation processes to ensure their sustainability. Accreditation is a significant tool for ensuring the quality of medical education programs [59].In this context, accreditation processes can contribute to the evaluation of the quality of the developed educational programs and the advocacy of their continuous improvement. Conclusion In this study, a program framework was proposed for integrating HL into medical curricula based on interviews with faculty members and qualitative findings (Table 2). The views of faculty members with different periods of experience will enrich these education programs. The existence of communication skills programmes within many medical faculties, which have accumulated considerable experience, creates an opportunity for the integration of HL. The findings of this study emphasize the importance of integrating HL with clinical skills through communication and clinical skills education programs implemented in the preclinical period and bedside education in the clinical years. In this context, defining the social and cultural patterns experienced by the society and patients and developing communication skills education programs accordingly will contribute. Within this framework, educational programs to be integrated into and implemented within medical education curricula will enhance students' knowledge, attitudes, and skills in addressing different levels of HL. Consequently, it is anticipated that these programs will contribute to improving the overall health of the community. Declarations Author Contribution All authors contributed to the design and concept. B.A., T.Ç., S.T., S.Ü., and H.Ö. took part in data collection. B.A., T.Ç., and S.T. performed the analyses. B.A., T.Ç., and S.T. wrote the main manuscript text. B.A. prepared tables. All authors reviewed the manuscript. Declaration of Interest Statement : We have no declarations of interest to report. Support Resources: The study was conducted within the framework of an Erasmus+ European Union Project of Strategic Partnership. Clinical Trial Number: Not applicable. References Simonds S. Health education as social policy. Health Education Monograph 1974;2:1-25. WHO. Health Literacy. In: Kickbusch I, Pelikan LM, Apfel F, Tsouros AD, editors. World Health Organization, Regional Office for Europe, 2013. Sørensen K, den Broucke SV, Fullam J, et al. Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health. 2012;12:80. Liu YB, Liu L, Li YF, et al. Relationship between Health Literacy, Health- Related Behaviors and Health Status: A Survey of Elderly Chinese. Int J Environ Res Public Health. 2015;12(8):9714-25. Weiss BD. Health literacy research: Isn’t there something better we could be doing? Health Commun. 2015;30(12):1173-1175. Adkins RN, Corus C. Health literacy for improved health outcomes: Effective capital in the marketplace. JConsum Aff. 2009;43(2):199-222. Kaper MS, Reijneveld SA, van Es FD, et al. Effectiveness of a comprehensive health literacy consultation skills training for undergraduate medical students: A randomized controlled trial. Int J Environ Res Public Health. 2020;17(1):81. Sacks K, Kim B. 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Washington (DC): National Academies Press (US); 2004. Coleman C, Peterson-Perry S, Sachdeva B, et al. Long-term Effects of a Health Literacy Curriculum for Family Medicine Residents. PRiMER. 2017;1:22. Güner MD, Ekmekci PE. A Survey Study Evaluating and Comparing the Health Literacy Knowledge and Communication Skills Used by Nurses and Physicians. Inquiry. 2019;56:46958019865831. Coleman C. Teaching health care professionals about health literacy: a review of the literature. Nurs Outlook. 2011;59(2):70-8. HELEM-EU. Development and Integration of Health Literacy Education With Innovative Methods in Medical Curricula Across Europe. About Project. https://www.helemeu.org/tr/.Accessed 20 March 2025. Yıldırım A, Şimşek H. Sosyal bilimlerde nitel araştırma yöntemleri [Qualitative research methods in social sciences] (10th edition) Ankara: Seçkin. Extended Summary; 2016. Turkish. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349-57. Parker RM, Gazmararian JA. Health literacy: essential for health communication. J Health Commun. 2003;8(S1):116-118. Levinson W, Lesser CS, Epstein RM. Developing physician communication skills for patient-centered care. Health Aff (Millwood). 2010;29(7):1310-8. Schwartzberg JG, VanGeest JB, Wang CC (Eds.) Understanding Health Literacy: Implications for Medicine and Public Health. American Medical Association Press; 2005. Koh HK, Brach C, Harris LM, et al. A proposed 'health literate care model' would constitute a systems approach to improving patients' engagement in care. Health Aff (Millwood). 2013;32(2):357-67. Galli G, Yates S, Strasser S.Incorporating health literacy in medical education. International Journal of Medical Education. 2019;10:247-248. Sayek I, Turan S, Batı AH, et al. Social accountability: A national framework for Turkish medical schools. Med Teach. 2021;43(2):223-231. Hubinette M, Dobson S, Scott I, et al. Health advocacy. Med Teach. 2017;39(2):128-135. Institute of Medicine (US) Committee on Health Literacy. Health Literacy: A Prescription to End Confusion. National Academies Press; 2004. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. Oxford University Press; 2013. The CanMEDS 2015 Framework. https://canmeds.royalcollege.ca/en/framework.Accessed 23 March 2025. General Medical Council.Tomorrow’s Doctors: Outcomes and standards for undergraduate medical education. The Lancet 2009;374(9693):851. Mezuniyet Öncesi Tıp Eğitimi Ulusal Çekirdek Eğitim Programı, 2020 [National Core Curriculum for Undergraduate Medical Education, 2020]. https://www.yok.gov.tr/Documents/Kurumsal/egitim_ogretim_dairesi/Ulusal-cekirdek-egitimi-programlari/mezuniyet-oncesi-tip-egitimi-cekirdek-egitimi-programi.pdf.Accessed 22 March 2025. Barnabe C, Osei-Tutu K, Maniate JM, et al. Equity, diversity, inclusion, and social justice in CanMEDS 2025. Can Med Educ J. 2023;14(1):27-32. WHO-ASPHER Competency Framework for the Public Health Workforce in the European Region, 2020. https://www.aspher.org/who-aspher-competency-framework-phw.html.Accessed 23 March 2025. Coleman CA, Hudson S, Maine LL. Health literacy practices and educational competencies for health professionals: a consensus study. J Health Commun. 2013;18 Suppl 1(Suppl 1):82-102. Bleakley A, Bligh J, Browne J. Medical Education for the Future: Identity, Power and Location. Springer; 2011. Steinert Y. Student perceptions of effective small group teaching. Med Educ. 2004;38(3):286-93. Kolb DA. Experiential learning: experience as the source of learning and development, 1984. https://www.fullerton.edu/cice/_resources/pdfs/sl_documents/Experiential%20Learning%20-%20Experience%20As%20The%20Source%20Of%20Learning%20and%20Development.pdf.Accessed 23 March 2025. Datta R, Upadhyay K, Jaideep C. Simulation and its role in medical education. Med J Armed Forces India. 2012;68(2):167-72. McGaghie WC, Issenberg SB, Petrusa ER, Scalese RJ. A critical review of simulation-based medical education research: 2003-2009. Med Educ. 2010;44(1):50-63. Nestel D, Tierney T. Role-play for medical students learning about communication: guidelines for maximising benefits. BMC Med Educ. 2007;7:3. Burgess A, Goulston K, Oates K. Role modelling of clinical tutors: a focus group study among medical students. BMC Med Educ. 2015;15:17. SnellYS, Linda S.Interactive lecturing: strategies for increasing participation in large group presentations. Med Teach. 1999;21(1):37–42. White CB, Gruppen LD, Fantone JC. Self-regulated learning in medical education. Med Educ. 2010;44(1):25-33. DeciEL,Ryan RM.The “What” and “Why” of Goal Pursuits: Human Needs and the Self-Determination of Behavior. Psychological Inquiry 2000;11(4):227–268. Kim S, Jeong H, Cho H, et al. Extracurricular activities in medical education: an integrative literature review. BMC Med Educ. 2023;23(1):278. Epstein RM.Assessment in medical education.NEngl J. Med 2007;356(4):387-396. Speyer R, Pilz W, Van Der Kruis J, et al. Reliability and validity of student peer assessment in medical education: a systematic review. Med Teach. 2011;33(11):e572-85. Shumway JM, Harden RM; Association for Medical Education in Europe. AMEE Guide No. 25: The assessment of learning outcomes for the competent and reflective physician. Med Teach. 2003;25(6):569-84. Connell L, Finn Y, Sixsmith J. Health literacy education programmes developed for qualified health professionals: a scoping review. BMJ Open. 2023;13(3):e070734. Harden RM. International medical education and future directions: a global perspective. Acad Med. 2006;81(12 Suppl):S22-9. Tables Tables 1 to 2 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files Table1.docx Table2.docx Appendix.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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05:41:19","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":30779,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-6290004/v1/4c843edfe9d558b0371ee56b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Health Literacy in Medical Curricula: A Framework Proposal Grounded in Qualitative Research","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe concept of health literacy (HL) was initially introduced by Simond in a 1974 article entitled \u0026ldquo;Health Education as Social Policy\u0026rdquo; [1]. Subsequently, in 1988, the World Health Organization (WHO) defined health literacy as \u003cem\u003e\u0026ldquo;the cognitive and social skills that determine the motivation and ability of individuals to access, understand, and use information in ways that promote and maintain good health\u0026rdquo;\u003c/em\u003e [2]. In a subsequent analysis of definitions of health literacy in 2012, S\u0026oslash;rensen and colleagues (2012) noted that \u003cem\u003e\u0026ldquo;health literacy is related to general literacy,\u0026rdquo;\u003c/em\u003e and developed a definition as \u003cem\u003e\u0026ldquo;the ability to access health-related information, to develop and make judgments and decisions about health issues throughout life, to protect, maintain, and improve health, and to understand and interpret health-related messages and information accurately, as well as the willingness and capacity to do so in order to enhance quality of life\u0026rdquo;\u003c/em\u003e[3].\u003c/p\u003e \u003cp\u003eHLis a broad concept encompassing the domains of literacy, adult education, and health promotion. HL, which has become a priority for health in the 21st century, given its pivotal role in enabling individuals to manage their own health. Individuals with low HL levels face difficulties accessing and utilizing healthcare services, encounter challenges in comprehending health information, and consequently, are less able to make proper health decisions. This has been associated with adverse health outcomes and elevated healthcare expenditures [4\u0026ndash;7].However, data from the United States (US) in 2022 indicates that at least 88% of adults living in the US have insufficient HL to effectively benefit from the healthcare system and support their well-being (55% have intermediate proficiency, 22% have basic proficiency, and 14% fall below basic proficiency), with only 12% have adequate health literacy[8]. In Germany, using the German Health Literacy Survey 2 (HLS-GER 2), a study conducted in 2019\u0026ndash;2020 with a representative sample of 2,151 German-speaking residents aged 18 and over, revealed that 58.8% of participants had low HL levels, with at least one-third of the survey questions rated as \u0026ldquo;difficult\u0026rdquo; or \u0026ldquo;very difficult.\u0026rdquo; Many participants reported challenges in accessing information (48.3%), understanding information (47.7%), applying information (53.5%), and evaluating information (74.7%) [9].Similarly, in Spain, a 2023 study utilizing the European Health Literacy Survey Questionnaire Short Form (HLS19-Q12) found that 59% of participants had insufficient or problematic HL levels. The strongest determinants of HL scores were identified as education, health status, and income [10].In T\u0026uuml;rkiye, the implementation of the Health Literacy Action Plan 2022\u0026ndash;2026 has led to notable improvements, as evidenced by a comparative evaluation of nationwide surveys conducted with 15,000 participants in 2017 and 2023. The proportion of individuals with adequate HL levels increased significantly from 31.9% in 2017 to 46.1% in 2023. Additionally, significant improvements in disease prevention and health promotion were observed, with adequate HL levels in disease prevention rising from 28.4\u0026ndash;45.7% [11].\u003c/p\u003e \u003cp\u003eEvidence suggests that healthcare providers equipped with an approach to HL and communication skills can make a positive contribution to reducing barriers related to HL and improving healthcare quality and patient outcomes [12\u0026ndash;14].However, studies have shown that healthcare providers often lack the necessary approach to HL competency to appropriately address and respond to patients' low HL issues [15,16]. The increasing complexity of healthcare delivery systems has made it even more critical to enhance the approach to HL competency of healthcare providers [17,18].The future medical profession will require a more extensiveapproach to HL capacities to empowerpatients\u0026rsquo; autonomy, engagement, and self-management skills [7]. Although most medical students will assume healthcare professional roles post-graduation, research on the HL levels of medical students remains limited. A study conducted in China with 1,275 participants found that third-year students scored the highest, while first-year students scored the lowest on all scales. Additionally, analyses revealed that socioeconomic status and parental education levels were positively associated with HL [19].In another study in Australia, the HL profiles of 86 participants enrolled in a medical education program were assessed using the 9-domain, 44-item Health Literacy Questionnaire (HLQ). Their results were then compared with national data from the Australian Bureau of Statistics. Notably, students scored significantly lower than the general Australian population in Domain 6 (ability to actively engage with healthcare providers) and Domain 7 (ability to navigate the healthcare system) [20].\u003c/p\u003e \u003cp\u003eIn line with these studies, a considerable number of medical educators and researchers have suggested that approach to HL education should be integrated into medical education curricula. Various programs are being developed for medical students to improve their approach to HL, and their effects are being examined through intervention studies. However, research in this area also remains limited. A study conducted in the United States involved approximately 100 second-year medical students participating in a workshop that was part of a mandatory course. The workshop comprised a review, observation and practical element focusing on three HL communication techniques: teach-back, the avoidance of medical jargon, and effective questioning. It was determined that this skill-based workshop could enhance medical students' confidence in employing HL communication practices [21].Another study was conducted in the Netherlands using a randomized controlled design. In this study, medical students (intervention group: 39; control group: 40) were assessed on their self-reported competencies (HL level, attitude, self-efficacy, and knowledge and awareness regarding patient-centered communication techniques) at baseline, after an 11-hour educational intervention, and during five- and ten-week follow-ups. The intervention group demonstrated significantly higher HL competencies, with the most remarkable improvements observed in providing clear information, shared decision-making, and self-management areas [7].Despite these endeavours, only a limited number of undergraduate or continuing medical education programs have integrated HL into their curricula [18,22\u0026ndash;24].Coleman emphasises that one of the most significant challenges in integrating HL into existing healthcare professional curricula is the lack of clear and widely accepted guidelines to define and evaluate the content of HL curricula across healthcare professional programs [25].\u003c/p\u003e \u003cp\u003eAn Erasmus\u0026thinsp;+\u0026thinsp;Strategic Partnership in Higher Education European Union Project (Development and Integration of Health Literacy Education with Innovative Methods in Medical Curricula Across Europe, HELEM-EU) was conductedin collaboration with partners from T\u0026uuml;rkiye, the Netherlands, Spain and Italy in order to contribute to meeting the need in this field and to develop and disseminate medical education programs on HL. The main aim of the project is to develop, implement, evaluate and integrate a novel HL education program into medical curricula through utilisasing of a peer learning methodology to enhance the basic undergraduate education and competencies of medical doctors [26]. One of the sub-studies undertaken in the course of developing the project was conducted in a medical faculty, which is one of the project's partners in Turkey, to examine the experiences of medical educators with regard to health literacy and their recommendations for educational programmes. The study sought answers to two research questions: \u0026ldquo;What competencies do they suggest should be developed for health literacy?\u0026rdquo; and \u0026lsquo;What are their suggestions for a health literacy program in terms of methodology, content and assessment and evaluation?\u0026rsquo;. The findings from this qualitative study are shared in this article, along with a framework for integrating HL education into medical curricula.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eResearch Design\u003c/h2\u003e \u003cp\u003eThis study was conducted using a qualitative research method with a phenomenological design [27].The data were collected online through semi-structured, in-depth interviews conducted via a video conferencing platform, in consideration of the necessity of maintaining social distancing during the pandemic. The interviews were conducted between May 4 and June 6, 2021.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eResearch Group\u003c/h3\u003e\n\u003cp\u003eThe study group consisted of faculty members from three different disciplines: internal sciences, surgical sciences, and basic sciences. To ensure diversity in data collection, the maximum variation sampling method was applied to select the participants. The first level of variation was implemented by determining the disciplines. Faculty members from different disciplines and departments were selected to the extent possible. Considering the aim of reaching data saturation, interviews were conducted with 20 faculty members from 20 different departments, including 8 from internal sciences, 8 from surgical sciences, and 4 from basic sciences. The distribution of the interviewed faculty members is presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eSix of the faculty members participating in the interviews held the title of professor, five held the title of associate professor, five had the title of assistant professor, and four held the title of lecturer doctor. The faculty comprised 12 women and 8 men. Their ages ranged between 32 and 62 years, and their years of graduation from medical school ranged between 1987 and 2005 (16 to 34 years as of the year of the study).\u003c/p\u003e\n\u003ch3\u003eData Collection Tool\u003c/h3\u003e\n\u003cp\u003eThe study utilized a 12-question interview form developed by the researchers. After drafting the form, a pilot test was conducted with two faculty members. Since no significant changes were made to the questions following the pilot test, the interviews conducted during this phase were included in the data.\u003c/p\u003e\n\u003ch3\u003eData Collection Process\u003c/h3\u003e\n\u003cp\u003eThe research team consisted of researchers specialized in public health and medical education and experienced in qualitative research. Interviews were conducted by researchers with extensive experience in qualitative interviews (ST, HO, SU, BA), and junior researchers accompanied the interviews to gain experience in qualitative research. The interviews lasted a minimum of 30 minutes and a maximum of 77 minutes.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eContent analysis was used to analyze the data. Through content analysis, the codes emerging from the interview data were combined to identify themes, aiming to explain concepts and relationships. The data analysis was carried out independently through the following steps, with the research team convening after each step to reach a consensus:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eThe interview audio recordings were transcribed by an experienced transcriptionist.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAllresearchers reviewedthewrittentranscripts. Spelling errors and parts thatwereunclear were corrected. The data were described to establish the study\u0026rsquo;sframework.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAll transcripts were read independently by the researchers, and code lists were created. Subsequently, the research team discussed the individual code lists, resolving discrepancies by collaboratively refining the meanings of concepts and achieving a high level of agreement.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eParagraphs were accepted as the unit of analysis. The data were divided into units of analysis. Excel program was used for coding and analysis to manage quotes and organize the data. All data were transferred into Excel in paragraphs.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eFour researchers independently coded the first interview transcript (117 units) using the consolidated code list. All researchers in the study group came together and discussed the code given to each paragraph together to reach a consensus.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAfter the consensus process, the consistency among the coders was calculated. Theresearchersindependentlycodedasingletranscriptfrom the dataset, and pairwise consistency was assessed. The agreement coefficient betweenthetwocoderswiththehighestconsistencywascalculatedas0.89for95dataunits. These two coders (BA, T\u0026Ccedil;) then divided the dataset and continued independent coding.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe two coders maintained communication during their work, discussing the code list and adding new suggestions or revisions to the main code list. A common opinion was formed at each stage.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAfter the coding was completed, the data were described based on the themes and codes, and the findings were written. The results were defined and interpreted, with participants' views presented in direct quotations using quotation marks. Any information that could reveal the participants'identities was removed from the quotations, and basic characteristics (gender, title, and participant number) were provided in parentheses at the end of each quote.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eValidity and reliability\u003c/h2\u003e \u003cp\u003eTo ensure validity in this study, participants were selected from various disciplines and fields to provide an in-depth understanding of the research question. Diversity was incorporated to represent different experiences and perspectives.\u003c/p\u003e \u003cp\u003eThe interview forms were developed with the participation of all members of the research team who had expertise in the field. Pilot tests were conducted for the interview forms and process. During the data collection phase, care was taken to create a positive and natural interview environment to ensure the collection of high-quality data. At each stage of the research and data analysis process, the research team reviewed and discussed the progress. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used to report this study [28].Findings were presented under themes, using unbiased direct quotations.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical Issues\u003c/h3\u003e\n\u003cp\u003e The study was examined at the meeting of the Gazi University Ethics Commission held on 23.3.2021 (Number: E-77082166-604.01.02-59610) and found ethically appropriate. Faculty members were contacted by e-mail and telephone and informed about the study.Theywereaskedfortheirinformedconsenttoparticipate,andthe informed consent form was shared via e-mail. The participants' permission was also obtained for audio and video recording during the interviews. Confidentiality was ensured for recordings and analysis. The research report does not contain information directly indicating the identity of the interviewees.\u003c/p\u003e\n\u003ch3\u003eLimitations of the Study\u003c/h3\u003e\n\u003cp\u003eThis research demonstrates the limitations of the interview technique in qualitative studies. The data was obtained from a semi-structured interview with the participants,whichwas based on their self-report.\u003c/p\u003e \u003cp\u003eAlthough efforts were made to ensure maximum diversity in the study, the findings do not represent the situation and context of all medical faculties. By the nature of qualitative studies, the study reflects the views of the faculty members who participated. Therefore, the generalizability of the findings is limited.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn this study, faculty members\u0026rsquo; opinions and recommendations regarding the development and integration of health literacy programs into medical education curricula were categorized in seven themes: competencies, content, teaching methods and techniques, assessment and evaluation, program structure/location and timing, faculty preparation, and program dissemination and motivation. Each of these themes offers a comprehensive examination of the key elements essential for the development of HL programs, addressing different dimensions of medical education programs. The findings, which serve as recommendations for medical education programs, highlight the expected competencies related to health literacy for graduates, the place and scope of HL programs within medical curricula, proposed content, teaching methods and techniques, assessment and evaluation methods, as well as faculty preparation and motivation. Examples of quotations related to the themes summarized in this section can be found in Appendix.\u003c/p\u003e \u003cp\u003e \u003cb\u003eRecommendations for HL and Its Structuring within Medical Education Programs\u003c/b\u003e \u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e1. Competencies\u003c/h2\u003e \u003cp\u003eIn the study, the participants were invited to share their insights on the identification of competencies in the programs intended for the development of health literacy. The participants were asked to express their views on the essential characteristics that should be exhibited by physicians who demonstrate an understanding of health literacy and are able to conduct effective patient-physician interviews for this purpose. The suggestions developed were identified and summarised under the theme of competencies for health literacy. It was observed that the role of \"communicator\" emerged as one of the most frequently mentioned themes. The recurrence of this theme underscores the significance of \"effective communication\" as a fundamental competency in fostering a patient-physician collaboration based on HL.\u003c/p\u003e \u003cp\u003e To be able to interview applicants/patients with varying levels of HL requires managing difficult situations, determining communication methods according to changing contexts and applicants, and restructuring processes.Consequently, it is important to focus on the development of existing communication skills programs and to ensure that communication skills include communication with both patients and colleagues in the development or integration of HL for medical education programs.\u003c/p\u003e \u003cp\u003eThe fact that issues such as being an expert in the field, following and implementing the most up-to-date evidence-based diagnosis and treatment processes are among the frequently emphasized issues shows that health professionals need adequate field knowledge and continuous learning and self-improvement skills. While continuous learning and development constitute a pivotal aspect of medicine, it is a more significant and prioritised domain for the implementation of HL skills. In addition, the importance of transferring the information to the community and the individual in health service delivery, taking into account their characteristics, needs and expectations, by creating or using appropriate materials is emphasized. The frequent mention of elements such as adherence to ethical principles, integrity and honesty emphasizes the importance of a professional understanding based on trust. It is seen that skills such as respect for differences, caring for the patient, honesty and transparency, and emotion management should not be neglected in terms of HL. These findings suggest that competencies such as communicator, expert/scientific, educator/informant, and adopting ethical values are indispensable for HL programs.\u003c/p\u003e \u003cp\u003eIt is also recommended that health professionals possess teamwork and leadership skills, a willingness to self-evaluate and seek continuous improvement, familiarity with the community they serve, the ability to advocate for health issues, effective time management, and the capacity to assess health literacy levels.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e2. Content\u003c/h2\u003e \u003cp\u003eIt was proposed that training programs related to HL should include subjects such as communication, communication skills in difficult situations, crisis management, and the significance of HL. These recommendations indicate that medical education should encompass not only the acquisition of technical knowledge and skills but also the development of non-technical skills such as communication and stress management. Another suggested themewas assessing the HL level of the applicant and the patient.\u003c/p\u003e \u003cp\u003eAt the same time, it is suggested to enrich the scope of HL programs by incorporating the social dimension of health services and medical education from a broader perspective such as sociology, psychology, community recognition and social accountability. Another critical issue concerning HL is emphasized under the title of \u0026ldquo;management of misinformation dissemination\u0026rdquo;. Moreover, contents such as stress management, crisis management and time management were defined as being related to HL programs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3. Teaching methods and techniques\u003c/h2\u003e \u003cp\u003eIn the sub-theme of teaching methods and techniques, it is seen that learner-centered and interactive learning methods and techniques are highlighted. Within the small group methods, it is suggested to diversify active learning methods and thus create teaching environments that will provide students with experience in HL. It is emphasized to use methods such as simulations, discussion, case studies, role-playing, movie watching and field studies.These methods indicate an emphasis on providing opportunities for experiential and hands-on learning, focusing more on developing students' skills rather than relying solely on theoretical knowledge and lecture-based methods.\u003c/p\u003e \u003cp\u003eClinical practices also play an important role in this process, asthey aim to provide students with experience in real patient environments. In addition, it was suggested that public education and extracurricular activities provide opportunities for medical students to develop community service and social responsibility awareness.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e4. Measurement and evaluation\u003c/h2\u003e \u003cp\u003eAssessment and evaluation processes play a critical role in determining student outcomes and evaluating the quality and impact of medical education. It is noteworthy that, similarto teaching methods, measurement and evaluation methods arerecommendedto focus mainly on practice and performance assessment. Performance assessment, direct observation, simulation-based assessment methods, and practical exams such as OSCE are important in evaluating how students transfer what they have learned into practice. Self-assessment and peer assessment can also be employed simultaneously at this stage.\u003c/p\u003e \u003cp\u003eFormative assessment supports the learning process by providing students with continuous feedback. In this context, the inclusion of feedback and reflection will allow students to evaluate themselves and continuously review their progress. Onlyoneperson suggested conducting a theoretical exam for knowledge level.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e5. The place and timing of HL in medical education programs\u003c/h2\u003e \u003cp\u003eIn the interviews, it was emphasized that HL programs should be \u0026ldquo;structured education programs.\u0026rdquo; Regarding the timing of these programs, it is significantly stated that a vertical program should be created, with the pre-clinical period serving as the starting point and the clinical years augmenting and enriching the program. Furthermore, emphasis is placed on the continuity of the process and the significance of integration, suggesting its incorporation into both specialisation and continuous professional development activities, particularly during the post-graduation period.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e6. Preparation of faculty members\u003c/h2\u003e \u003cp\u003eThe preparation of faculty members is also a crucial part of this process. In particular, faculty members' role modeling, mentoring and ownership of the program were mentioned among the factors that enhance the success of training programs. Additionally, their experience in the field and communication skills also play a critical role in this process. These findings underscore that, in medical education, faculty members should not only serve as conveyors of knowledge but also role models, mentors and guides.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e7. Dissemination of Training Programs\u003c/h2\u003e \u003cp\u003eAccreditation processes of medical education programs aim to maintain and improve quality standards in education. It was emphasized as an opinion that the inclusion of HL in medical education accreditation standards could contribute to the dissemination of programs and the encouragement of medical faculties.\u003c/p\u003e \u003cp\u003eThe faculty members participating in the study approached HL programs within medical education from a broad perspective.They addressed various elements of the programs, from structured training to content and methodological diversity, as well as performance-based assessment and evaluation processes. They emphasized the importance of ensuring methodological diversity and incorporating continuous feedback mechanisms through the active participation of both faculty members and students at every stage of the educational process.\u003c/p\u003e \u003cp\u003eAccording to the findings of the study, the general features of the HL program framework can be summarized as follows:\u003c/p\u003e \u003cp\u003e1. Scope of the competency frameworks (in addition to the defined competencies for medical students)\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eUnderstanding and recognizing society, developing social and cultural awareness\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eCommunicating appropriately according to the HL levels\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eManaging the spread of misinformation\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDeveloping of teaching skills\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e2. Structuring the HL education program:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eVertically integrated and continuous education starting at an early stage\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHumanities and social sciences education\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eElective courses\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eExtra-curricular student group activities\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e3. Teaching methods and techniques\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eSmall group work,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eInteractive (active) learning methods\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eGuidance from faculty members\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e4. Strengthening assessment and evaluation methods:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePerformance-based assessment methods\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePeer assessment and self-evaluation\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e5. Dissemination of programs\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eInstitutional ownership\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMonitoring quality through accreditation\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe consensus among all participants in this study was that enhancing health literacy in health professionals\u0026rsquo; education would enhance the quality of health services and contribute to public health beyond the mere improvement of society's capacity to access information [29]. The integration of health literacy education into medical education programs was thus recommended. In alignment with the opinions of the study's participants, a program framework was developed that encompasses recommendations on the design and implementation of medical education programs. This framework encompasses competencies, content, learning-teaching methods and assessment and evaluation elements (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe most prominent competency area in the study was communication. All participants emphasized that communication is an essential skill that should be acquired in medical education and that effective communication with the patient, appropriate to the level of HL and free of medical terminology, positively affects treatmentcompliance. This suggestion is supported by guidelines developed and studies conducted in the field of patient-physician communication, which accept the importance of patient-physician communication appropriate to the level of HL without medical terminology as critical in patient-centred healthcare [30,31].\u003c/p\u003e \u003cp\u003eParticipants highlight that the ability to recognize social and individual differences, respect cultural values and establish a trust-based relationship with patients by anticipating the effects of these factors on health outcomes can be gained through structured training programs. The effects of social determinants of health on individual and community health are indisputable. Identifying these effects and transferring them to patient-physician communication will contribute to establishing a trust-based relationship as well as increasing the quality of health or care processes. In this context, it is accepted that being aware of and supporting cultural and social differences in health processes should be a part of medical education [31\u0026ndash;34]. Other competencies emphasized in the study to support this competency were recognitionof the society and health advocacy. The views included analyzing the society, foreseeing needs, suggesting change and leading the way. These competencies align with the views in the literature that health professionals should be individuals who create change, have a vision, define reasons for change, direct change, and be role models [35]. In this context, leadership has also found its place among the defined competencies.\u003c/p\u003e \u003cp\u003eIn the study, communication and having the scientific knowledge of the field stand out among the competencies defined. In today's rapidly evolving world, possessing knowledge in a specific field will remain limited without the ability for continuous development. In line with this, the views reported in the study include recommendations for health professionals to maintain and enhance their professional competencies through continuous learning and to adopt an inquisitive, investigative and critical approach to their practices. These competencies encompass accessing up-to-date information and practices, applying them in service delivery and sharing them with patients. Participants also emphasized that accurate information sharing with patients and society requires educational skills beyond communication skills.Similarly, the Institute of Medicine (2004) report highlights the importance of physicians developing teaching skills and maintaining motivation for lifelong learning to enhance the health literacy of the population [36].\u003c/p\u003e \u003cp\u003eThe competencies emphasize two key aspects that form the foundation of the medical profession: the adoption of ethical values and respect for the profession. Adoption of ethical values enables the physician to act in accordance with patient rights, human dignity and professional responsibilities. These values are based on principles such as trust, justice, honesty, and prioritizing patient welfare[37]. Commitment to ethical values is not only a cornerstone of the quality of medical practices but also the foundation of trust-building patient-physician communication. It is crucial to address this focus in health literacy programs as well.\u003c/p\u003e \u003cp\u003eAn examination of the international and Turkish physician competency frameworks [33-40]reveals that competencies such as expertise in the field, effective communication, leadership, collaboration, professionalism and health advocacy, which are prominent in this study, exhibit significant overlap despite the use of varying expressions. In addition to the competencies aligned with the national and international frameworks, this study proposes a new competency: \"identifying the level of health literacy (HL)\". This competency is regarded as an essential skill for initiating patient-physician communication. In the course of the interviews, this competency was defined in different scopes for the community and the individual, and it was stated that it is one of the starting areas for the physician in planning care and service. Another competency suggestion that differs from the competency frameworks is that of being an educator.\u003c/p\u003e \u003cp\u003eAlthough national and international medical education competency frameworks contain detailed competencies in the areas of communication skills and health advocacy, they are limited in meeting the competencies emphasized in this study, such as society recognition, educational role, social accountability, patient education and intercultural sensitivity. Similarly, Barnabe et al. (2023) draw attention to the fact that CanMEDS 2015, a widely accepted physician competency framework, does not include competencies for concepts such as equality, cultural safety, diversity, inclusion and social justice and argue that an update study should be conducted [41]. In this context, the National Medical Education Competencies in T\u0026uuml;rkiye (U\u0026Ccedil;EP, 2020) has a broader framework. This document employs a biopsychosocial approach, encompassing the protection and enhancement of public health, the concepts of social accountability and social obligation, and the sociodemographic and sociocultural characteristics of the individual.. However, in this document, the competencies for determining and implementing communication strategies appropriate to the social and cultural structure of the society and the individual and differences are limited or scattered in different sections of the competencies[40]. Another aspect of competency frameworks not covered in the context of our findings is the definition of the physician's role as an educator. While the concept of providing health education is mentioned in these frameworks, competencies such as developing educational skills, providing clear and understandable information, and offering education tailored to the HL level of the community have not been directly addressed. From the perspective of HL programs, these competencies stand out as distinct from others and should be considered when developing such programs.\u003c/p\u003e \u003cp\u003eFor these recommendations, it is helpful to examine the WHO-ASPHER (World Health Organization- The Association of Schools of Public Health in the European Region) European List of Core Competencies for Public Health Professionals. Although this framework is aimed at the public health workforce, it is stated that some of the core competencies are aimed at all health professionals due to the nature of public health and the differences arising from the structuring of public health services in some countries. One of the competencies in this framework is health promotion. As an umbrella concept, health promotion consists of competencies for improving, protecting and preventing diseases. In the WHO-ASPHER Framework, this competency includes education and promotion through community participation, health literacy at community, organizational and individual levels, empowerment of citizens, assessment of health needs, screening and secondary prevention, and evaluation of health promotion interventions and programs. These definitions make it necessary to look at health services beyond a disease and treatment perspective. General medical competency frameworks have this perspective to a limited extent. This perspective needs to be taken into consideration not only in HL program competencies but also in the updating of general medical competency frameworks [42].\u003c/p\u003e \u003cp\u003eThe participants proposed including modules/courses in medical education that address the understanding and evaluation of health communication and health literacy levels. In this context, they suggested incorporating communication in difficult situations, effective communication, empathy, the prevention of misinformation dissemination, sociology and psychology for understanding people and society, the importance of HL and the evaluation of HL levels into the programme content. In medical education, communication skills are considered as the most fundamental, critically essential non-technical skills[30]. Effective communication is contingent upon first evaluating the patient's health literacy level and determining suitable communication methods, thereby enhancing compliance with health services, care and treatment [32,43].The study emphasised the imperative of incorporating subjects such as sociology and psychology into medical education programmes to cultivate competencies in comprehending society, considering social contexts, and assuming social accountability, in accordance with the extant literature [44]. Another prominent issue is the concept of misinformation dissemination. In order to ensure that people have access to the guidance they need, especially in times of crisis, the inclusion of the management of misinformation dissemination within the scope of medical education will enable physicians to improve their skills in directing society or individuals to reliable sources and raising public awareness [33].The experience during the COVID-19 pandemic has clearly demonstrated the importance of managing the spread of misinformation.\u003c/p\u003e \u003cp\u003e Participants emphasized the importance of conducting teaching activities in interactive and small groups. Educational activities conducted in small groups contribute to the development of learners' communication skills as well as increase learning motivation and retention by ensuring that learners are active [45]. Activities such as simulations, case discussions, role play, movie discussions and field practices, which stand out in the statements within the scope of small group trainings, show that it is preferred to create learning opportunities by using problem-solving skills by doing and experiencing instead of transferring theoretical knowledge. This is in line with Kolb's (1984) Experiential Learning Theory in the context of prioritizing analyzing knowledge, learning through experience and using it in real life [46]. Simulation is a teaching technique that facilitates learning in areas such as the development of communication skills and crisis management through practice, reflection and feedback by eliminating the risks in real life experience [47,48].Roleplay, movie discussions and case discussions also help learners to recognize social and cultural contexts, develop ethical attitudes, and gain skills such as understanding the patient and empathizing [49].Practices carried out in the field provide students with the opportunity to encounter and directly interact with the community they will serve in the future while also providing them with skills to improve public health [44].Previous studies have also highlighted that, particularly in small group educational activities, instructors' comprehension of the curriculum, interest in teaching, and ability to create a positive learning environment can enhance learners' motivation and ensure the retention of knowledge [50,51].Utilizing these methods will contribute to the development of multiple competency areas, thereby increasing the effectiveness of teaching.\u003c/p\u003e \u003cp\u003eSome participants suggested that HL programs and courses should be mandatory, while others recommended offering them as electives or through interest clubs. The opportunity for students to voluntarily and willingly participate in elective courses or interest club activities is among the emphasized advantages for fostering learning motivation. Elective courses provide students with the opportunity to engage in in-depth learning in areas of interest, develop self-directed learning skills, and enhance their motivation to learn [52]. Extracurricular voluntary activities, such as student community events and interest clubs, not only foster intrinsic motivation but also strengthen students' social bonds, enhance their professional skills, and equip them with competencies in areas like the social determinants of health, health management, and developing health-promoting policies [53,54].Programs developed in this direction can be implemented through different approaches or a combination of these, tailored to the conditions of the schools.\u003c/p\u003e \u003cp\u003eIt is expressed that measurement and evaluation throughout the process, in line with competencies, goal-oriented, learner-centered, evidence-based, systematic and transparent methods will motivate learning. Self-assessment, peer assessment, reflection, simulation-based and OSCE are among the measurement methods emphasized. Epstein (2007) emphasizes that multi-process-oriented methods designed to measure competencies not only assess skills such as communication, clinical decision-making, and problem-solving but also foster lifelong learning motivation [55].Peer and self-assessment methods, which are also prominent in the study, enable learners to take responsibility for their learning, become aware of their strengths and weaknesses, and gain the habit of receiving and giving feedback [56].Shumway and Harden (2003) state that self- and peer-assessment are used in the evaluation of attitudes and communication skills in the field of medical education [57].Simulation-based and objective structured clinical exams, developed according to educational objectives, allow the measurement of clinical skills, interpersonal behaviors, and communication skills in realistic and safe environments, while also providing learners with feedback to support their development [55].In summary, as with teaching methods, it is emphasized that assessment tools should be designed to be goal-oriented, focused on skill development, performance-based, and applied, ensuring that feedback is provided not only on outcomes but also throughout the process.\u003c/p\u003e \u003cp\u003eThe place and timing of the HL programs in the curriculum are important. The most frequently emphasized recommendation in the study is the implementation of structured vertical programs starting early in undergraduate education, from the first years, with increasing intensity through clinical and postgraduate phases, and extending to continuous professional development programs. The Institute of Medicine (2004) report also recommends that trainings aimed at developing HL skills should be integrated in a way that provides reinforcement in the clinical period [36].Studies on developing HL programs for health professionals and evaluating their effectiveness are limited. In a study conducted with family medicine residents, 12 first-year family medicine residents participated in four HL trainings over 11 months, and pre-post assessments were conducted. The participants' knowledge levels showed significant improvement immediately after the training. In communication skills, only two (asking open-ended questions and checking understanding) showed permanent improvement at the 11-month follow-up, and the other six behaviors, although progress was made during the training, were not maintained in the long term. The results of the study show that information is quickly learned but that it is challenging to integrate skills into clinical practice [23].As these studies also reveal, this vertical integration needs to be ensured in order to reinforce and develop competencies.\u003c/p\u003e \u003cp\u003eA review study on HL training programs for health professionals identified 26 articles on HL training and 27 on HL-related communication. Most studies were non-randomized, longitudinal, and used pre-post evaluations. A total of 35 studies incorporated both didactic and experiential teaching methods, with experiential techniques including role-playing (n\u0026thinsp;=\u0026thinsp;23) and workshops (n\u0026thinsp;=\u0026thinsp;15). Regarding HL-specific interventions, all 26 studies included educational content, while 16 featured written and oral examples of best practices, 13 provided a general HL overview, and five focused on self-management and empowerment. HL-related communication skills interventions covered various strategies such as the \u0026ldquo;teach-back\u0026rdquo; method, avoiding jargon, summarizing information, asking open-ended questions, and teaching shared decision-making. Most studies did not report barriers to implementing HL knowledge and skills (n\u0026thinsp;=\u0026thinsp;45) or information about the facilitators (n\u0026thinsp;=\u0026thinsp;52). Reported barriers included difficulties in applying learning, behavioral changes, overcoming habits, overestimating competencies, adapting training to daily practice, sustainability concerns, and resource limitations. Other challenges included individual pressures to use technical language and organizational obstacles, such as a lack of faculty role models, time constraints, and competing clinical priorities. And, facilitators included institutional commitment, leadership and administrative support, HL advocates within the organization, and an institutional focus on HL [58].The study emphasized the need for innovative teaching and assessment methods to enhance performance, rather than relying solely on didactic instruction and knowledge transfer.\u003c/p\u003e \u003cp\u003eInstitutional and faculty preparedness are crucial for the success and implementation of programs. In the study, opinions on the contribution of faculty members' preparation, their experiences in getting to know the society and maintaining appropriate communication, mentoring and role modelling for students, and their motivation to create an environment that supports learning goals to the effectiveness and sustainability of HL programs came to the fore. The study thus posits that a participatory approach during the programme development process, in conjunction with the implementation of an effective communication strategy during the dissemination phase, is a prerequisite for the preparation of institutions, faculty members, and students for the application of these programmes. A further recommendation from the study is the integration of these programmes into accreditation processes to ensure their sustainability. Accreditation is a significant tool for ensuring the quality of medical education programs [59].In this context, accreditation processes can contribute to the evaluation of the quality of the developed educational programs and the advocacy of their continuous improvement.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this study, a program framework was proposed for integrating HL into medical curricula based on interviews with faculty members and qualitative findings (Table 2). The views of faculty members with different periods of experience will enrich these education programs. The existence of communication skills programmes within many medical faculties, which have accumulated considerable experience, creates an opportunity for the integration of HL. The findings of this study emphasize the importance of integrating HL with clinical skills through communication and clinical skills education programs implemented in the preclinical period and bedside education in the clinical years. In this context, defining the social and cultural patterns experienced by the society and patients and developing communication skills education programs accordingly will contribute. Within this framework, educational programs to be integrated into and implemented within medical education curricula will enhance students' knowledge, attitudes, and skills in addressing different levels of HL. Consequently, it is anticipated that these programs will contribute to improving the overall health of the community.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the design and concept. B.A., T.\u0026Ccedil;., S.T., S.\u0026Uuml;., and H.\u0026Ouml;. took part in data collection. B.A., T.\u0026Ccedil;., and S.T. performed the analyses. B.A., T.\u0026Ccedil;., and S.T. wrote the main manuscript text. B.A. prepared tables. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Interest Statement\u003c/strong\u003e: We have no declarations of interest to report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupport Resources:\u003c/strong\u003e The study was conducted within the framework of an Erasmus+ European Union Project of Strategic Partnership.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number:\u003c/strong\u003e Not applicable.\u003c/p\u003e"},{"header":" References","content":"\u003col\u003e\n\u003cli\u003eSimonds S. Health education as social policy. Health Education Monograph 1974;2:1-25.\u003c/li\u003e\n\u003cli\u003eWHO. Health Literacy. In: Kickbusch I, Pelikan LM, Apfel F, Tsouros AD, editors. 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Acad Med. 2006;81(12 Suppl):S22-9.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 2 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Health literacy, Curriculum, Medical education, Qualitative study","lastPublishedDoi":"10.21203/rs.3.rs-6290004/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6290004/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eIn the qualitative study conducted within the scope of the HELEM-EU project, which was planned and implemented to integrate the health literacy (HL) education program into medical school curricula, the opinions of medical educators were obtained regarding this education program. In this article, the program framework created based on the findings of this qualitative research is presented.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis study used a qualitative research method with a phenomenological design. The data were collected online through semi-structured, in-depth interviews conducted via a video conferencing platform between May 4 and June 6, 2021, with 20 faculty members from 20 different departments. Content analysis was used to analyze the data. Through content analysis, the codes emerging from the interview data were combined to identify themes, aiming to explain concepts and relationships.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eFaculty members’ opinions and recommendations regarding the development and integration of HL programs into medical education curricula were categorized into seven themes: competencies, content, teaching methods and techniques, assessment and evaluation, program structure/location and timing, faculty preparation, and program dissemination and motivation. One of the most frequently mentioned themes is the \"communicator\" role that faculty members believe a HL education program should impart. It was proposed that training programs related to HL should include subjects such as communication, communication skills in difficult situations, crisis management, and the significance of HL. In the theme of teaching methods and techniques, it is seen that interactive methods and techniques are emphasized, just like measurement and evaluation methods. In the interviews, it is suggested that HL programs should be “structured education programs”, a vertical program should be created and they should be included in continuous professional development activities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eBased on the qualitative findings, the HL educational programs that will be integrated into the medical school curriculum within the framework of the proposed program will increase the knowledge, attitudes and skills of the students towards different levels of HL. Consequently, it is anticipated that these programs will contribute to improving the community's overall health.\u003c/p\u003e","manuscriptTitle":"Health Literacy in Medical Curricula: A Framework Proposal Grounded in Qualitative Research","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-01 05:33:14","doi":"10.21203/rs.3.rs-6290004/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"908ee201-f54b-41e3-8e6a-ffae5c0b4a41","owner":[],"postedDate":"April 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-28T08:24:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-01 05:33:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6290004","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6290004","identity":"rs-6290004","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}