Youth Deliberation and Health Literacy in Portugal: Evidence from the Mini-Assemblies of Health and the Youth Health Choices Forum

Abstract

Digital ecosystems, misinformation exposure, mental-health vulnerability and unequal access to care create distinctive challenges for young people. Although youth participation in health governance is increasingly advocated internationally, structured evidence from youth deliberative processes remains limited in Portugal. This study synthesises priorities expressed in two Portuguese deliberative initiatives coordinated by the Sociedade Portuguesa de Literacia em Saúde: the Mini-Assemblies of Health 2022–2023, with particular attention to the 3rd Mini-Assembly on Fighting Health Misinformation, and the Youth Health Choices Forum 2024. Both processes used a structured nominal-group logic to support idea generation, clarification, recording and prioritisation. The analysis used low-inference cross-session thematic aggregation to preserve propositional integrity and remain close to participants’ formulations. Five priority domains were identified: digital health communication and information credibility; curriculum-integrated and peer-mediated health literacy; low-friction mental-health access and stigma reduction; equity and functional service accessibility and governance, accountability and youth participation. Participant quotations are retained, in translated form, to preserve youth voice and to show how recommendations emerged from concrete deliberative formulations. The findings suggest that nominal group technique (NGT)-based youth deliberation can generate operational recommendations for policy and practice, including credibility mechanisms for digital health information, school-based health-literacy integration, autonomy-preserving access routes for mental-health support, and permanent youth participation structures. The findings support recognising young people not only as vulnerable recipients of health information but also as interpreters of digital health ecosystems and contributors to the design of more responsive health governance.

1. Introduction

Young people increasingly navigate health decisions within digital environments marked by information abundance, misinformation exposure and uneven credibility signals. These challenges are particularly relevant to health literacy, mental health and access to care, because young people often seek information and support across social media platforms, peer networks, schools and formal health services. In Portugal, the Mini-Assemblies of Health were explicitly created to make citizen voice visible in health policy reflection, with health literacy understood through access, comprehension, use of health resources, system navigation and decision-making across the life course (Vaz de Almeida et al., 2024b).

However, structured empirical evidence on how young people deliberate about health literacy remains limited in Portugal. A preliminary EBSCO scoping search conducted on 29 May 2026 using the exact query “Youth Deliberation AND Health Literacy” returned no records. Because adjacent literature may be indexed under alternative terms, this result is treated as an indication of weak indexing for the exact concept combination rather than as evidence of absence. In particular, little is known about how youth participants themselves prioritise digital health communication, misinformation control, mental-health access, service usability and health-governance participation through structured deliberative processes. This study addresses this gap by analysing two national initiatives and examining how participating young people formulated priorities for health literacy and youth health governance.

Recent adolescent health-literacy research helps clarify why this issue is particularly relevant for youth populations. Fleary and Joseph (2020) show that adolescents use health literacy both actively and passively in health decision-making and that this use is shaped by individual factors, including future orientation and risk perception, and environmental factors, including access to resources, media, family support and provider communication. Their findings show adolescent health literacy operating as a practical decision-making resource rather than as functional reading ability alone. Complementarily, Paakkari and Paakkari (2012) conceptualise health literacy as a school learning outcome encompassing theoretical and practical knowledge, critical thinking, self-awareness and citizenship. Together, these studies support an understanding of youth health literacy as situated, developmental and connected to everyday choices, while the present study extends this perspective by examining how young people themselves prioritise health-literacy and governance actions through structured deliberation.

This emphasis is also consistent with multidimensional models of health literacy. Nutbeam (2000) distinguishes functional, interactive and critical health literacy, while Manganello (2008) and Levin-Zamir et al. (2011) emphasise the relevance of media health literacy for adolescents. Sørensen et al. (2012) further conceptualise health literacy through competencies of accessing, understanding, appraising and applying information across healthcare, disease prevention and health promotion. These frameworks illuminate the Portuguese youth deliberations, in which participants called not only for more health content but also for credible digital signals, peer-mediated interpretation, emotionally meaningful communication and institutional conditions that enable them to appraise and use information in real decisions.

Deliberative citizen participation in health policy has been recognised as a component of democratic governance and evidence-informed decision-making, particularly where policy decisions depend on legitimacy, inclusion and public trust (Pagatpatan & Ward, 2017; World Health Organization, 2021). Deliberative mini-publics and related forms of structured engagement seek to translate citizen input into legitimate and actionable recommendations, especially when participation is designed to avoid tokenism and to create transparent pathways between public input and institutional response (Escobar & Elstub, 2017; Setälä & Smith, 2018). Recent scoping work on public and patient involvement also highlights the need for clearer reporting of involvement methods, design conditions and policy uptake pathways in health policy decision-making (Baumann et al., 2022).

The quality of public deliberation is also a methodological issue when deliberative outputs are expected to inform public decisions. Draucker et al. (2026) argue that qualitative evaluation of public deliberation can be strengthened through enhanced qualitative analysis, including directed content analysis using deliberation principles, distribution tables based on frequency code counts, and inductive analysis of the nature of coded remarks. Their findings show that protocol refinement and facilitator training can benefit from systematic attention to whether participants challenge views, provide reasons for stated opinions, adopt a societal perspective and apply expert information in their arguments.

Deliberation also has a distinct tradition in bioethics. In this context, deliberation is understood as a form of practical reasoning that examines the relevant facts, identifies the values and duties in conflict, compares the foreseeable consequences of feasible courses of action, and seeks a prudent decision that can be publicly justified (Gracia, 2001, 2003; Molewijk et al., 2008). This approach resists a premature dilemma mentality that reduces morally complex situations to two mutually exclusive options. By explicitly identifying extreme and intermediate courses of action, bioethical deliberation broadens the decision space and supports proportionate, context-sensitive choices that seek to protect as many of the values at stake as possible (Gracia, 2001, 2003).

Bioethical deliberation is further enriched by narrative and hermeneutical approaches. Narrative bioethics treats accounts of illness, vulnerability, identity and care as morally relevant forms of knowledge because they disclose how a situation is experienced and what may remain obscured by abstract categories alone (Charon & Montello, 1999, 2002; Nelson, 1997; Porz et al., 2011). Its hermeneutical orientation requires attention to voice, context, relationships, symbolic meanings and asymmetries of interpretation (Porz et al., 2011; Russo, 2021). For youth health governance, this perspective is relevant because transparency depends not only on making information available, but also on creating conditions in which young people can articulate how digital environments, stigma, institutional distance and service design are lived and interpreted (Charon & Montello, 2002; Lundy, 2007; World Health Organization, 2021).

Combining these traditions clarifies the analytical role of the initiatives examined here. NGT supplies a structured procedure intended to broaden participation, reduce dominance and generate prioritised proposals (Harvey & Holmes, 2012; MacPhail, 2001; McMillan et al., 2016); bioethical deliberation explains why competing values and multiple courses of action should be examined (Gracia, 2001, 2003; Molewijk et al., 2008); and narrative bioethics explains why lived meanings and participant voice must remain visible in that process (Charon & Montello, 2002; Nelson, 1997; Porz et al., 2011). The sessions did not implement a formal clinical-bioethics protocol; these bodies of literature instead provide complementary theoretical lenses for understanding how structured youth deliberation may support more reasoned, context-sensitive, and accountable health decisions.

Among structured group techniques for priority setting, the NGT is particularly relevant. Originally developed by Delbecq and Van de Ven (1971), and later systematised for programme planning by Delbecq et al. (1975), NGT uses explicit procedural stages—silent idea generation, round-robin contribution, clarification, clustering, and ranking—to reduce dominance bias and support equal participation opportunities. In health research, NGT has been used to identify priorities, generate indicators, co-develop action plans, and adapt consensus-building to clinical and public health settings (Harb et al., 2021; Harvey & Holmes, 2012; McMillan et al., 2016; Rankin et al., 2016). MacPhail (2001) also discusses NGT as a useful technique for working with young school-aged people, stressing its structured procedures and its relevance to equity and accuracy in group-based elicitation.

The suitability of NGT for youth-related health processes is supported by studies showing that structured facilitation can enable young people to contribute to evidence synthesis, priority setting and intervention design. Evans et al. (2017), for example, used NGT to involve young people in an evidence synthesis on risk in inpatient mental-health care, showing the technique’s capacity to support voice and agency in adolescent groups. Related participatory work with students, including student citizens’ assemblies in higher education settings, further demonstrates the potential of deliberative techniques to involve young people in co-creating health and wellbeing interventions (Bellicha et al., 2024). Nyalela and Dlungwane (2024) provide a recent example of NGT applied to co-create health-service intervention strategies, reinforcing the technique’s usefulness for turning group input into practical recommendations.

The present study analyses two Portuguese youth deliberative initiatives: the Mini-Assemblies of Health 2022–2023, with particular attention to the 3rd Mini-Assembly on Fighting Health Misinformation, and the Youth Health Choices Forum 2024. The aim is to synthesise the priorities expressed by young participants and to identify policy-oriented recommendations for digital health communication, school-based health literacy, low-threshold mental-health access, equity of service use, and institutional youth participation.

2. Materials and Methods

2.1. Study Design and Paradigm

This study uses a qualitative public-deliberation design grounded in decision-oriented research and documentary analysis, with a qualitative descriptive orientation. A qualitative descriptive orientation is appropriate when the aim is to provide an account that remains close to the data and to participants’ formulations (Sandelowski, 2000, 2010). Complementarily, document analysis entails the systematic examination and interpretation of documentary materials and supports corroboration across sources (Bowen, 2009). The objective is not to estimate population prevalence or produce statistical inference, but to systematise prioritised recommendations generated through structured youth deliberation. This approach is also consistent with utilisation-oriented and decision-oriented research traditions, where the value of evidence lies in its capacity to inform action, policy design and institutional learning (Draucker et al., 2026; M. Q. Patton, 2008; Rittel & Webber, 1973). Deliberative approaches are especially relevant to complex policy problems that require social legitimacy, structured participation and transparent translation of public input into recommendations (Bächtiger et al., 2018; World Health Organization, 2021).

2.2. Empirical Sources and Corpus

Two national initiatives were analysed (Table 1). Both were coordinated by the Sociedade Portuguesa de Literacia em Saúde and were methodologically harmonised through a nominal-group deliberative logic. The information generated in the assemblies and forums was directly observed and documented during the deliberative processes through facilitator and rapporteur records, photographic and video capture of the events, and visual documentation of participant-generated and session materials. The corpus combined published institutional reports with an observational-documentary archive generated during the deliberative processes. It included the Mini-Assemblies of Health White Paper report (Livro Branco Miniassembleias da Saúde) and the Youth Health Choices Forum report (Opções dos Jovens para a Saúde), ranked proposals and recorded group recommendations, programme and session materials, visual documentation of written or presentation materials used or produced during the events, facilitator or rapporteur documentation where available, and selected verbatim or near-verbatim formulations documented in the reports or transcribed from youth contributions (Vaz de Almeida et al., 2024a, 2024b). This heterogeneous corpus was not treated only as a limitation, but also as a methodological condition of the study. To manage it, the analysis used low-inference synthesis and traceability procedures, focusing on how youth priorities were formulated across different deliberative materials and participation formats. The Mini-Assemblies of Health White Paper report records 93 participants across the four Mini-Assemblies of Health, including groups of migrants, people with disabilities, young people and older people, with 20 young participants in the 3rd Mini-Assembly on Fighting Health Misinformation. The Youth Health Choices Forum report (Vaz de Almeida et al., 2024a) identifies 13 named youth representatives from youth and student organisations.

Table 1. Empirical sources analysed.

Process	Period	Nature	Participants Represented	Deliberative Focus
Mini-Assemblies of Health, including the 3rd Mini-Assembly on Fighting Health Misinformation	2022–2023	Local and thematic deliberative sessions	Young people and diverse public groups. The Mini-Assemblies of Health White Paper report records 93 participants across the overall Mini-Assemblies programme; the youth component of the 3rd Mini-Assembly included 20 young participants and is identified through APJF participation.	Misinformation, health literacy, trust in health information, youth-oriented communication and service access
Youth Health Choices Forum/Opções dos Jovens para a Saúde	2024	National summit of youth leaders	Youth association leaders and student representatives (n = 13) from ANEEP, ANEM, ANEN, ANEP, ANJF, APEF, APJF, the Conselho Nacional da Juventude and the youth office of the Ordem dos Médicos Veterinários (expanded in Section 2.3).	Access to care, mental health, governance, participation and health literacy

2.3. Participants, Prompts and Recruitment

The 3rd Mini-Assembly on Fighting Health Misinformation took place on 17 December 2022 at the César Batalha Auditorium in Oeiras, Portugal. The empirical record for this component was built from direct observation of the event; facilitator and rapporteur records; photographic and video documentation, including visual records of written, presentation and session materials produced or used by participants during the activity; and the subsequently published Mini-Assemblies of Health White Paper report (Livro Branco Miniassembleias da Saúde). The available empirical and published documentation identifies the participation of the Associação Portuguesa de Jovens Farmacêuticos (APJF) and states that participants authorised audio, video and photographic recording and the reference to names in that report. This Mini-Assembly component involved 20 young participants. Participants worked with stimulus words related to health, misinformation, prevention, access, credibility, sources, comprehension, health literacy, fake news, choices, motives, beliefs and awareness. Direct observation and the documented records indicate that the listening process followed the same nominal-group procedure as the other Mini-Assemblies: groups discussed proposals, selected representatives to present them, and proposals were recorded and voted on. This source forms the youth Mini-Assembly corpus described in Table 1.

The Youth Health Choices Forum took place on 6 March 2024 at the Conselho Nacional da Juventude in Lisbon and was co-organised by the Sociedade Portuguesa de Literacia em Saúde and the Conselho Nacional da Juventude. The report identifies representatives from youth and student organisations, including the Associação Nacional de Estudantes de Enfermagem em Portugal (ANEEP), Associação Nacional de Estudantes de Medicina (ANEM), Associação Nacional de Estudantes de Nutrição (ANEN), Associação Nacional de Estudantes de Psicologia (ANEP), Associação Nacional de Jovens na Fisioterapia (ANJF), Associação Portuguesa de Estudantes de Farmácia (APEF), Associação Portuguesa de Jovens Farmacêuticos (APJF), the Conselho Nacional da Juventude and the youth office of the Ordem dos Médicos Veterinários. For this component, the corpus included the published report and documented materials, including transcribed youth contributions. It is therefore analysed as a youth-leader and youth-representative deliberative source rather than as a statistically representative youth sample. This source forms the youth-leader forum corpus described in Table 1.

2.4. NGT Procedure

The NGT was applied through a structured sequence across the deliberative sessions. The Mini-Assemblies of Health White Paper report describes the presentation of the objectives, use of printed stimulus words, group discussion, election of a group speaker, sequential recording of proposals, individual voting by show of hands, and registration of the five most voted proposals (Vaz de Almeida et al., 2024b). The analysis therefore treats structured idea generation, clarification, clustering, prioritisation and validation as the common procedural logic, while noting that the documented voting modality in the Mini-Assemblies was a show of hands, whereas the modality may have differed in other associated sessions.

• Idea generation. Participants generated proposals in response to prompts such as health, information, trust, access, support, digital, credibility, misinformation and literacy.
• Group sharing. Participants presented proposals to the group; all proposals were documented by rapporteurs or facilitators.
• Clarification. Clarification focused on understanding the meaning of proposals without argumentative evaluation.
• Clustering. Facilitators grouped semantically related proposals while preserving original phrasing and avoiding the merger of distinct solutions.
• Structured prioritisation. Participants selected priority proposals through the voting mechanism documented for each process. In the Mini-Assemblies, voting was by show of hands, one proposal at a time.
• Validation and reporting. The five most voted proposals were registered, and all proposals were preserved as part of the source record.

2.5. Cross-Session Analytical Strategy

Data were synthesised using low-inference thematic aggregation (Table 2). Data organisation and management were supported by MAXQDA 26.3 (VERBI Software, Berlin, Germany), which facilitated the organisation of extracted proposals, the development and management of analytical categories, the grouping of source excerpts, cross-session comparison, and the construction of synthesis tables and the analytical audit trail. All analytical decisions remained author-led. This analytical strategy was informed by a qualitative descriptive orientation, which prioritises an account that remains close to the data and to participants’ formulations (Sandelowski, 2000, 2010), and by document analysis, which entails the systematic examination and interpretation of documentary materials and supports corroboration across sources (Bowen, 2009). The analysis focused on what participants proposed rather than on speculative interpretation of why they proposed it. Cross-session synthesis preserved propositional integrity, meaning and directional intent; lexical duplication was removed only when proposals expressed the same action or demand. Informed by Draucker et al. (2026) and qualitative trustworthiness guidance (Nowell et al., 2017; Tracy, 2010), the analytical strategy treated deliberative quality as partly dependent on transparent documentation of the link between deliberative remarks, prioritised recommendations, and interpretive claims. Although the Youth Health Choices Forum included transcribed youth contributions from participating youth representatives, the corpus did not include full verbatim transcripts for all sessions across both initiatives. Because full verbatim transcripts were unavailable for all sessions, the analysis was not designed as a comprehensive transcript-based assessment of deliberative quality. The study therefore adopts a low-inference observational and documentary approach, operationalised through a qualitative descriptive orientation, systematic document analysis, and transparent audit trails (Bowen, 2009; Nowell et al., 2017; Sandelowski, 2000, 2010). This approach is designed to preserve traceability across direct observations, photographic and video records, session materials, facilitator and rapporteur records, transcribed youth contributions, source reports, quotations, and the resulting recommendations. Analytical reliability was addressed through a two-stage author review: one author conducted the primary extraction and cross-session thematic aggregation, and a second author audited the complete mapping between source formulations, thematic clusters and final domains against the institutional reports and the observational-documentary archive. This was a source-fidelity audit rather than independent blind double coding; accordingly, no intercoder agreement coefficient was calculated. Formal intercoder reliability represents one possible quality strategy in qualitative analysis, whereas transparency, reflexive dialogue and an auditable decision trail may be more appropriate for consensus-based interpretive designs (Nowell et al., 2017; O’Connor & Joffe, 2020). Differences were resolved by consensus after returning to the original Portuguese formulation and its documentary context, and the least inferential categorisation was retained whenever more than one interpretation remained plausible. Supplementary Table S1 records the resulting quotation- and formulation-level traceability chain. Low-inference aggregation governed the descriptive analysis reported in the Results; the Discussion subsequently situated these findings within bioethical, participation-rights, source-credibility and related theoretical frameworks. These frameworks informed interpretation but were not part of the empirical coding scheme.

Table 2. Analytical levels and fidelity criteria.

Analytical Level	Objective	Fidelity Criterion
Intra-session/intra-group	Verify integrity of recorded proposals	All proposals preserved before clustering
Inter-session/inter-group	Aggregate themes and remove lexical duplication	Meaning and directional intent preserved
Cross-session synthesis	Identify recurrent and stable priorities	Convergence interpreted descriptively rather than statistically

2.6. Ethical Considerations

Participation in the original deliberative initiatives was voluntary. The Mini-Assemblies of Health White Paper report indicates authorisation for audio, video and photographic recording and for reference to names in the youth Mini-Assembly. This study is an observational-documentary qualitative analysis of deliberative processes that had already taken place. It draws on direct observation, facilitator and rapporteur documentation, participant-generated and session materials, visual records, published reports and, where available, transcribed youth contributions. It did not involve new recruitment, new interaction with participants, clinical intervention or collection of new personal data for the purposes of the analysis. For publication, quotations are treated as deliberative material and are presented in translated form without additional personal identifiers. Only statements traceable to the documented source material are retained as participant quotations. The facilitation approach was non-directive and consistent with recommendations for deliberative citizen engagement.

3. Results

Across the analysed deliberative processes, young participants articulated health literacy not as episodic information delivery, but as an infrastructure of trust, access and participation. The prioritised recommendations and documented deliberative materials from the Mini-Assembly on youth and misinformation, complemented by the Youth Health Choices Forum, converged around five interrelated priority domains: digital health communication and information credibility; curriculum-integrated and peer-mediated health literacy; low-friction mental-health access and stigma reduction; equity and functional service accessibility; and governance, accountability and youth participation. The quotations below are retained to preserve youth voice. Unless otherwise indicated, they are translated from Portuguese source material and illustrate the deliberative logic behind the recommendations; they are not used to support statistical generalisation. The five-domain synthesis is condensed in Table 3.

Table 3. Cross-source synthesis of youth health-governance demands.

Domain	Policy Logic	Source Process and Operational Requirement
Digital health communication and information credibility	Credibility as a visible and verifiable public asset	Primary source process: 3rd Mini-Assembly on Fighting Health Misinformation; reinforced by the Youth Health Choices Forum. Operational requirement: cross-platform credibility seal; platform-native content; collaboration with credentialled health communicators; student- and youth-association partnerships.
Curriculum-integrated and peer-mediated health literacy	Health literacy as an educational right and participatory learning process	Primary source process: 3rd Mini-Assembly on Fighting Health Misinformation; reinforced by the Youth Health Choices Forum. Operational requirement: school-embedded progression; socio-emotional learning; peer brokers; storytelling; art and multimodal methods.
Low-friction mental-health access and stigma reduction	Agency through low-friction and stigma-free entry points	Source process: 3rd Mini-Assembly on Fighting Health Misinformation, with convergence in the Youth Health Choices Forum. Operational requirement: anonymous, rapid, digital and self-directed support; positive mental-health voucher; anti-stigma work.
Equity and functional service accessibility	Functional usability over formal availability	Source process: the youth Mini-Assembly and the broader Mini-Assemblies corpus, reinforced by the Youth Health Choices Forum. Operational requirement: provisional entitlements; digital interfaces; multilingual and accessible communication; adapted schedules; pharmacy-based literacy hubs.
Governance, accountability and youth participation	Participation as an accountable decision layer	Primary source process: Youth Health Choices Forum; reinforced by participation proposals in the 3rd Mini-Assembly. Operational requirement: permanent youth council; recommendation traceability; monitoring metrics; accountability and feedback loops.

3.1. Digital Communication, Platforms and Information Credibility

Young participants consistently treated digital platforms as central spaces for health communication and misinformation control. They argued that public health communication must operate within youth communication cultures rather than simply replicate institutional messages. In the Mini-Assembly, participants explicitly proposed capitalising on underused social networks, including Spotify and TikTok, and using health professionals already active online as health-literacy ambassadors. They also proposed strategic partnerships with student and youth associations, including common platforms to reach local populations and a national survey on youth health literacy and risk behaviours to identify needs and monitor priorities (Vaz de Almeida et al., 2024b).

“Social media is under-used. We need health communication on TikTok and even ads on Spotify.”

“There are good influencers—doctors, pharmacists. They could be health literacy ambassadors.”

“The Directorate-General of Health (DGS) should approach student associations and associations of young professionals to create common platforms to reach the local population.”

The findings indicate that the challenge concerned not the absence of health information, but the limited visibility and recognisability of credible sources on platforms where young people search, share and interpret content. Participants’ proposals therefore identify digital environments as sites of health decision-making, credibility assessment, and misinformation exposure, rather than merely as preferred communication channels.

A recurrent demand concerned the public signalling of trustworthy sources. Participants proposed a credibility rating system for digital health sources, using the metaphor of a “Michelin star” to describe a recognisable marker of reliability.

“Create a ‘Michelin star’ for digital health sources—credible social media—to assess credibility, foundations and sources.”

The proposal represents a practical navigation aid rather than a censorship mechanism, reflecting participants’ demand for recognisable cues to identify reliable health information in environments shaped by algorithms, influencers and contradictory claims.

3.2. Curriculum-Integrated and Peer-Mediated Health Literacy

Health literacy was repeatedly described as something that should be embedded in schools and youth environments rather than delivered through isolated awareness sessions. Participants criticised school-based sessions that were perceived as overly expository, biologically narrow or disconnected from lived concerns, especially in areas such as sexuality, drugs and risk behaviours. The source report notes that young people do not want to be judged on topics such as sexual education, and that conventional sessions often remain limited to contraception or biology rather than addressing what young people actually experience and worry about.

“In young people’s perception, these presentations are limited and remain focused on contraceptives or biology.”

“Young people do not want to be judged on topics such as sexual education.”

The Mini-Assembly report records three recurring claims about youth learning: young people need to feel freer and more at ease, socio-emotional competences need to be developed, and methods must allow young people to participate. Participants also argued that beliefs should not simply be contradicted, but clarified through active methodologies and communicative approaches adapted to youth cultures (Vaz de Almeida et al., 2024b).

“Young people need to feel more at ease, more free.”

“It is necessary to develop young people’s socio-emotional competences.”

“We need methods in which young people participate.”

Peer communication and affective learning were central to participants’ understanding of health literacy. Rather than positioning professionals as the only legitimate communicators, participants emphasised the role of peers, storytelling, art, poetry, audiovisual methods and shared experience. The report explicitly states that peer-to-peer communication is needed, that the affective component is very important and that socio-emotional competences should begin early in education (Vaz de Almeida et al., 2024b).

“What stays with us are emotions.”

Participants further connected learning to youth media practices and multimodal methods. One example from the report described a student recording videos with school material and later listening to and watching them as a learning strategy.

“My daughter records videos with the subject matter and then listens to herself and watches the videos.”

The pedagogical model proposed by participants was not one of simplification alone, but of reciprocity. Experts, teachers and facilitators were expected to communicate with credibility while also adopting a learning posture.

“The expert should not arrive as someone who knows everything, but as someone willing to learn with us.”

“I relate to the person through poetry, through art.”

“Access to information is very peer to peer. The message needs to be passed on.”

These statements support a model of health literacy as participatory, relational and affective. Participants did not reject expertise; rather, they requested formats that allow expertise to be communicated through proximity, emotional relevance and shared meaning-making.

“It is not enough to have access to information and put it into practice—assertive and informed choices are needed.”

3.3. Low-Friction Mental-Health Access and Stigma Reduction

Mental health emerged as one of the most urgent cross-cutting priorities. Participants called for investment in psychological support, de-stigmatisation of mental-health problems, and open discussion of stigma, fear, emotions and suicide. The proposals focused not only on service expansion but also on reducing the procedural and affective burden of asking for help, including rapid responses at the moment of need, prevention-oriented support, and autonomy-preserving access routes.

“What do young people want? For someone to respond quickly to their needs.”

The Mini-Assemblies of Health White Paper report documents a proposal for a positive mental-health cheque or voucher, framed as regular preventive action that could help young people seek screening and support. It also recommends debate sessions involving parents/guardians, older people and young people, indicating that mental-health literacy was understood as both an individual and intergenerational issue (Vaz de Almeida et al., 2024b).

“A regular action on mental health, with ‘cheques’—vouchers—for mental health could lead young people to seek screening.”

Participants also related mental-health vulnerability to body image, aesthetic procedures, influencer culture and pressure to conform to ideals of perfection. The source report explicitly notes that “the pressure of perfection continues to exist” and that young people may be particularly vulnerable because their sense of self is still developing.

“The pressure of perfection continues to exist. For young people, it is harder to understand because they do not yet have the self fully defined.”

Mental-health literacy was therefore linked not only to clinical access, but also to prevention, self-recognition, peer support, digital culture and protection from harmful norms of beauty, body and performance.

3.4. Equity and Functional Service Accessibility

Participants distinguished formal availability of services from actual usability. They argued that services are not effectively accessible when they are incompatible with young people’s time, language, digital habits or practical conditions. The Mini-Assemblies of Health White Paper report records that health centres were perceived as discredited among young people because they function poorly, use language that does not meet young people where they are, and have schedules that are not compatible with youth needs. Participants also argued that services should be more oriented towards health promotion and prevention rather than being symbolically associated only with illness (Vaz de Almeida et al., 2024b).

“The schedules are not youth-friendly.”

“Because it functions poorly and people cannot receive care, this creates a mismatch.”

“A proximity health unit being ‘zero digital’ pushes young people away.”

Participants also called for a more positive relationship with prevention and health promotion, rather than associating medical services only with illness.

“Going to the doctor is not a bad thing. We need to make health a good practice, without fear, a positive relationship with health.”

Several proposals focused on functional redesign: extending opening hours, creating digital interfaces, improving multilingual and youth-sensitive communication, mobilising pharmacies as local health-literacy hubs, and training journalists and health professionals in credible and accessible communication. The source report also includes a case in which poor communication in a hospital setting created an access barrier for a pregnant woman who did not share the clinician’s language.

“The doctor said she did not have time and did not understand the language. Health professionals should at least speak English. It is important to know how to communicate with users.”

Equity was also linked to migrants and young people facing administrative barriers. The broader Mini-Assemblies identified a provisional health-user card, simplified information, multilingual access, and better system navigation and mediation as important solutions for people who experience difficulty entering the health system (Vaz de Almeida et al., 2024b). These proposals reinforce the youth finding that access is not merely the existence of services, but the ability to use them when and how they are needed.

3.5. Governance, Accountability and Institutional Youth Participation

Young people rejected symbolic or merely advisory participation and argued for more permanent, accountable forms of youth involvement in health governance. The Mini-Assemblies of Health White Paper report repeatedly frames the Mini-Assemblies as a way of listening to citizens and returning their voice to decision-makers (Vaz de Almeida et al., 2024b). In the youth assembly, participants called for student and youth associations to help create credible content and asked for systematic listening to youth needs. The Youth Health Choices Forum reinforces this orientation: its opening message explicitly asks that young people be heard and called to participate in the new executive, and that they insist on being heard if participation does not occur (Vaz de Almeida et al., 2024a).

“I wish you to be heard, and to be called to participate in the new executive. If that does not happen, do not give up; insist on being heard.”

“Young people have a unique and innovative perspective on how to solve current challenges, many of which are persistent problems.”

Participants also emphasised monitoring and accountability. They argued that measures should be evaluated, with metrics defined to understand whether actions actually work. In the Youth Health Choices Forum, youth representation was framed as continuous and meaningful participation rather than episodic consultation, and the Conselho Nacional da Juventude was presented as a platform for listening and co-constructing solutions with young people.

The governance proposals included youth representation embedded in decision structures, public monitoring of adopted recommendations, feedback loops, association-based co-creation of content, and training for health professionals and journalists. These operational requirements are synthesised in Table 3. A Youth Health Literacy Council within the National Health Service was therefore framed as a possible institutional mechanism to move from episodic consultation to structured participation.

3.6. Cross-Domain Synthesis

Across domains, and as summarised in Table 3, participants framed misinformation not primarily as a deficit of facts, but as a symptom of relational and systemic asymmetries: mismatch of language and formats, weak institutional presence in youth digital spaces, procedural barriers to care, limited emotional safety and insufficient youth influence in decision-making. The proposed solutions moved beyond information supply towards system redesign: platform presence, credibility certification, peer mediation, curricular reform, rapid and anonymous mental-health support, functional access and institutionalised participation. In this sense, the results connect health literacy with youth agency: to be health literate is not only to understand information but to be able to recognise credible sources, ask questions, compare sources, participate in decisions, and access services that are designed for actual use.

Analytically, the findings suggest that health communication becomes credible for young people when it becomes less institutionally distant and more meaningful, emotionally engaging, and culturally recognisable.

“I find myself being the only person having fun in the room.”

This final statement illustrates a broader communicative challenge: health education and health communication must become meaningful, emotionally engaging and culturally recognisable to young people, rather than remaining formally correct but socially distant.

4. Discussion

This study shows that structured youth deliberation can generate concrete and policy-oriented priorities in health literacy and youth health governance. The findings reinforce the value of NGT as a technique for eliciting and prioritising recommendations through structured participation, while limiting domination by more vocal group members (Harvey & Holmes, 2012; MacPhail, 2001; McMillan et al., 2016). The Portuguese deliberative evidence is especially relevant because it connects health literacy with digital credibility, peer-mediated learning, mental-health access, functional service usability and institutional youth participation. The cross-domain structure and its source-specific traceability are summarised in Table 3. The original contribution of the article is to show how youth deliberative processes can convert dispersed concerns into operational recommendations for health literacy and health governance while retaining a visible link to the deliberative process from which each domain emerged.

4.1. From Information Deficits to Youth Health-Literacy Ecologies

A central contribution of the findings is that young participants did not conceptualise health literacy as a narrow problem of information transmission. Their proposals indicate a broader ecology of health literacy, involving access to understandable information, the ability to interpret and appraise competing sources, confidence to communicate with professionals, and opportunities to translate knowledge into decisions. This interpretation is consistent with multidimensional health-literacy models. Nutbeam (2000) distinguishes functional, interactive and critical health literacy; Manganello (2008) argues that adolescent health literacy must account for developmental, social and media environments; Levin-Zamir et al. (2011) specify media health literacy as an important dimension of how adolescents identify, interpret and act on health information in mediated environments; and Sørensen et al. (2012) frame health literacy through the competencies of accessing, understanding, appraising and applying information across healthcare, disease prevention and health promotion.

The analysed deliberative materials add empirical texture to these models. When participating young people asked for health communication on TikTok, Spotify, and social media, they were not merely asking for institutional messages to be placed on fashionable platforms. They were identifying digital environments as sites where health information is encountered, appraised, emotionally processed and socially circulated. Their demand for credible influencers, student associations and young health professionals as intermediaries suggests that health literacy is mediated through trust, social proximity and recognisable communicative codes. This is consistent with Bröder et al. (2017), whose systematic review of child and youth health-literacy definitions and models shows that young people’s health literacy is not reducible to individual reading skills; rather, it is shaped by developmental stage, social context, communication environments and structural opportunities for participation.

The contrast between institutionally distant information and information experienced as socially proximate and meaningful is particularly important. Research on web-based health information shows that credibility judgements are influenced by source authority, expertise, content features and usability cues, rather than by factual accuracy alone (Sbaffi & Rowley, 2017). In this context, the request for a “Michelin star” or credibility marker for digital health sources can be read as a demand for navigational infrastructure within complex information environments. It corresponds to media and critical health literacy: the capacity not only to receive information, but to evaluate who is speaking, how claims are justified, where evidence comes from and whether a source is trustworthy (Levin-Zamir et al., 2011; Nutbeam, 2000). In this sense, the proposed credibility seal is both a communication intervention and a health-literacy tool.

At the interpretive level, the participants’ preference for visible health professionals on social media also highlights the difference between source prominence and source validity. Celebrity-endorsement research shows that familiarity, attractiveness, status, and perceived trustworthiness can operate as persuasive cues, even when an endorser lacks domain-specific expertise (Hoffman & Tan, 2015; Knoll & Matthes, 2017; Ohanian, 1990). This influence is not confined to conventional advertising: experimental studies have found that sports-celebrity endorsement and social-media influencer marketing can affect children’s food preferences or intake in the specific contexts examined (Boyland et al., 2013; Coates et al., 2019). In digital health environments, fame may therefore confer an appearance of credibility without increasing the evidential quality, clinical relevance or methodological rigour of a recommendation (Hoffman & Tan, 2015; Sbaffi & Rowley, 2017).

Two related cognitive mechanisms help clarify this distinction. The availability heuristic concerns the use of ease of retrieval as a shortcut when judging frequency or probability (Tversky & Kahneman, 1973), whereas repetition and processing fluency can increase the perceived truth of a statement, including when prior knowledge should support rejection or when the repeated content is false (Fazio et al., 2015; Pennycook et al., 2018). In relation to the present findings, repeated exposure to a recognisable influencer may increase retrievability and familiarity even when the source’s health expertise, sponsorship and evidential basis remain uncertain. Although these mechanisms were not directly tested in this study, they provide a theoretically grounded explanation for participants’ simultaneous recognition of influencers’ communicative reach and preference for a stronger role for identifiable healthcare professionals. The resulting policy implication is to distinguish reach from epistemic authority through transparent credentials, disclosure of commercial relationships, citation of evidence and visible verification mechanisms (Hoffman & Tan, 2015; Sbaffi & Rowley, 2017).

This interpretation is strengthened by Fleary and Joseph (2020), who show that adolescents use health literacy actively and passively, and that their decision-making is shaped by media, access to resources, provider communication, feedback from others, confidence, and the ability to navigate multiple information sources. The Portuguese findings converge strongly with this evidence. Youth requests for peer communication, platform-native health content, trusted digital ambassadors and source-certification mechanisms are not superficial communication preferences; they are expressions of health-literacy needs in real decision-making environments. In practical terms, young people are asking for systems that help them move from exposure to information towards appraisal, confidence and action.

4.2. Peer Mediation, Affective Learning and School-Based Health Literacy

The results also deepen the understanding of school-based health literacy. Participants criticised episodic, expository, and narrowly biological sessions, especially in areas such as sexual health, and instead asked for participatory techniques and methods, socio-emotional competences, storytelling, arts-based approaches, and peer-to-peer communication. These findings echo Fleary and Joseph’s (2020) observation that adolescents’ confidence in health literacy is shaped by feedback from others, communication with adults, ability to consult multiple sources and opportunities to practise health-related skills. They also align with Paakkari and Paakkari’s (2012) conceptualisation of health literacy as a school learning outcome encompassing theoretical and practical knowledge, critical thinking, self-awareness and citizenship. This framework supports experiential and participatory learning conditions rather than reducing health literacy to the transmission of decontextualised information (Paakkari & Paakkari, 2012).

The analysed deliberative materials suggest that participating young people want health education to be emotionally memorable and socially credible. The quotation “What stays with us are emotions” is analytically significant because it challenges purely cognitive models of health education. It does not reject scientific accuracy; rather, it indicates that accurate information may fail if it is not communicated through formats capable of engaging attention, emotion, relevance, and identity. This is consistent with adolescent development literature, which emphasises adolescence as a period in which social belonging, peer influence, identity formation and future orientation are central to health behaviours and decision-making (G. C. Patton et al., 2016; Sawyer et al., 2012).

Peer mediation should therefore not be treated as a merely decorative youth-engagement strategy. In the data, peers appear as epistemic and relational brokers. They help translate health information into language, examples and situations that young people recognise. This is particularly important in sensitive topics such as sexuality, substance use, mental health, body image and misinformation, where stigma, embarrassment, concerns about confidentiality and difficulty trusting unfamiliar professionals are documented barriers to young people’s disclosure and help-seeking (Gulliver et al., 2010; Radez et al., 2021). The participants’ request that experts enter learning spaces “as apprentices” rather than as authorities who “know everything” indicates a preference for dialogical authority: expertise remains necessary, but it must be exercised through reciprocity, listening and co-construction.

These findings have practical consequences for curriculum design. They support embedding health literacy as a progressive curricular and extracurricular competence, combining evidence-based content, emotional literacy, peer mediation, digital literacy, arts-based methods and practical decision scenarios. Such an approach is consistent with models that distinguish functional, interactive, and critical health literacy, with media health literacy, and with school-based health literacy as a learning outcome that includes knowledge, critical thinking, self-awareness, and citizenship (Levin-Zamir et al., 2011; Nutbeam, 2000; Paakkari & Paakkari, 2012). In other words, the Portuguese deliberations point towards health literacy as a developmental competence that must be built over time, rather than as a topic addressed through isolated awareness sessions.

4.3. Mental Health, Autonomy and the Architecture of Access

Mental health emerged as a priority not only because participants recognised psychological distress, stigma and body-image pressures, but because they diagnosed the access pathway itself as burdensome. Systematic reviews show that stigma, embarrassment, preferences for self-reliance, confidentiality concerns and difficulties trusting professionals can impede young people’s help-seeking and access to mental-health care (Gulliver et al., 2010; Radez et al., 2021). The Portuguese results therefore shift the discussion from “more information about mental health” to the design of low-friction access systems. Participants asked for rapid responses, anonymity, reduced stigma, digital entry points and autonomy-preserving mechanisms such as mental-health vouchers or cheques. These proposals suggest that health literacy and service accessibility are inseparable: young people may recognise a need for support but still be unable or unwilling to seek help when the pathway entails exposure, delay, adult gatekeeping or repeated justification.

This finding resonates with evidence that adolescents’ use of health literacy depends on confidence, motivation, provider communication, access to resources and environmental support (Fleary & Joseph, 2020), and that autonomy, confidentiality and trust shape mental-health help-seeking (Gulliver et al., 2010; Radez et al., 2021). In the Portuguese deliberations, the mental-health voucher functions symbolically and practically as an autonomy device: it is intended to lower the threshold between recognising need and initiating care. The proposal is therefore not only about financing; it concerns agency, confidentiality and timing. This interpretation reflects the deliberative rationale expressed by participants; the effectiveness of a voucher mechanism remains to be evaluated empirically.

The body-image and perfection-pressure findings also matter. Participants linked mental-health vulnerability to influencer culture, aesthetic procedures and normative pressure. This concern is consistent with a systematic review reporting associations between social networking site use and body-image and disordered-eating outcomes, while also noting that much of the evidence was cross-sectional and therefore did not establish causality (Holland & Tiggemann, 2016). The findings reinforce the need to connect mental-health literacy with digital media literacy. Young people are not only exposed to health misinformation in the narrow sense of false claims; they are also exposed to aesthetic norms and social-comparison cues that may shape self-perception. The present study therefore supports examining mental health, media environments, emotional competences, and peer support as interconnected policy areas, without claiming that the deliberative corpus tested the causal effects of social media.

The global adolescent-health literature supports this integrated approach. Sawyer et al. (2012) describe adolescence as a foundation for future health, while G. C. Patton et al. (2016) emphasise that adolescent health and wellbeing are shaped by intersecting social, educational, technological and health-system forces. The present study contributes to this discussion by showing that young participants themselves articulate these intersections: they connect mental health to digital culture, services to schedules and usability, literacy to emotions, and participation to governance accountability.

4.4. Functional Access, Equity and Adolescent-Responsive Services

The access-related results show that young people distinguish formal availability from functional usability. A service may exist and still fail young users if its opening hours are incompatible with school or work, if its interfaces are not digital, if language is inaccessible, if professionals communicate in ways perceived as distant or judgemental, or if administrative procedures create delay and uncertainty. This distinction is essential for interpreting the proposals on “zero digital” health units, non-youth-friendly schedules, multilingual communication and pharmacies as community health-literacy hubs.

The WHO global standards for quality health-care services for adolescents emphasise that adolescent-responsive care requires more than clinical availability; services must be accessible, acceptable, equitable, appropriate and effective (World Health Organization, 2015). The Portuguese findings are consistent with this standards-based approach. Participants’ proposals identify service design features that influence whether young people actually use available resources: digital appointment and communication channels, extended opening hours, clear language, respectful interaction, privacy, and professionals trained to communicate with young users. This supports an interpretation of health literacy not only as a property of individuals but also as an organisational quality involving how systems make information and services easier or harder to find, understand, and use (Farmanova et al., 2018).

Equity also emerges as functional rather than only legal or formal. The broader Mini-Assemblies generated proposals related to migrant access, simplified information, provisional health-user cards, translation, system navigation and mediation. These are directly relevant to youth health because young migrants, young people from families with linguistic barriers, and youths with disabilities may experience compounded barriers. In this sense, youth health literacy must be intersectional in practice, even when the deliberative domains are analytically separated. The same young person may simultaneously need age-sensitive communication, multilingual information, digital access, confidentiality and support in navigating bureaucratic systems.

This interpretation also helps avoid an individualising reading of health literacy. If young people do not understand or use services, the problem is not necessarily lack of motivation or deficient knowledge. It may be that services are not designed around everyday rhythms, languages, technologies and concerns. This corresponds to organisational health literacy, which frames navigability, communication and service design as organisation-wide responsibilities rather than burdens placed solely on users (Farmanova et al., 2018). The participants’ statements therefore point towards health systems, schools and community organisations that are more navigable, responsive and communicatively competent.

4.5. From Consultation to Youth Governance

The governance dimension is a central finding of the study. Participants and youth leaders repeatedly framed young people as present and future health actors, not merely as recipients of education or care. The Youth Health Choices Forum brought together young representatives from student and professional associations, and the source report stresses the importance of hearing young people and involving them in public decision-making. The emphasis therefore extends beyond episodic consultation to sustained participation in health governance.

The participant-generated priorities can be interpreted through established frameworks of children’s and young people’s participation rights. Article 12 of the United Nations Convention on the Rights of the Child establishes the right of children capable of forming views to express those views freely in matters affecting them, with those views given due weight according to age and maturity (United Nations General Assembly, 1989). Lundy (2007) further argues that meaningful implementation of Article 12 requires not only voice, but also space, audience and influence. Lansdown’s (2005) work on the evolving capacities of the child supports the view that participation should expand as young people’s capacities, experience and contexts develop. Hart’s (1992) critique of tokenism is also relevant: participation is meaningful only when young people understand the process, have a real opportunity to influence outcomes and are not included merely symbolically. Together, these frameworks provide a normative lens for interpreting the empirical priorities; they were not part of the coding framework used to derive the study’s thematic domains.

The Portuguese findings correspond closely to this distinction. Young people did not ask simply to be heard once: they asked for mechanisms that return their voice to decision-makers, allow monitoring of adopted measures, and create accountability loops. The proposal for a Youth Health Literacy Council, or an equivalent permanent mechanism, represents an institutional response to a deliberative demand. Such a mechanism would be consistent with participation frameworks that connect voice to audience and influence, and with health-governance guidance emphasising institutionalised social participation and feedback (Lundy, 2007; World Health Organization, 2021).

These findings also contribute to deliberative-democracy and health policy literature. Mini-publics and structured deliberative formats are often valued because they can generate legitimate, informed and plural recommendations (Bächtiger et al., 2018; Escobar & Elstub, 2017; Setälä & Smith, 2018). However, their policy relevance depends on whether outputs are connected to decision pathways, feedback mechanisms and implementation responsibilities. The Portuguese case therefore demonstrates both the promise and the fragility of deliberative youth participation: NGT can produce prioritised recommendations, but institutional uptake requires structures that make youth input visible, traceable and consequential.

The findings contribute at three levels. Empirically, they document Portuguese youth priorities across digital health communication, peer-mediated and curricular health literacy, mental health, functional access and governance. Conceptually, they show how youth deliberation can transform dispersed concerns into structured health-literacy and policy priorities and then into concrete policy-facing recommendations. Methodologically, the study illustrates how NGT can combine individual contribution with collective prioritisation (Harvey & Holmes, 2012; McMillan et al., 2016) and how transparent source mapping and an auditable analytical trail can strengthen qualitative trustworthiness (Bowen, 2009; Nowell et al., 2017). Table 3 makes this movement analytically traceable by identifying the deliberative source associated with each domain and linking it to the resulting policy logic and operational requirement. The pathway represents the policy relevance of the deliberative evidence rather than measured downstream impact.

4.6. Limitations

The study is based on structured deliberative processes rather than on a representative survey of Portuguese youth. Findings should therefore be interpreted as priorities generated by participating young people and youth representatives, not as statistically generalisable claims about all young people in Portugal. The corpus combines initiatives with different scales and participant profiles. The Mini-Assemblies of Health White Paper report records 93 participants across the overall Mini-Assemblies programme, including 20 young participants in the 3rd Mini-Assembly on Fighting Health Misinformation. The Youth Health Choices Forum report (Vaz de Almeida et al., 2024a) documents 13 named youth representatives, which constitutes the documented count for the analysed forum corpus; it does not provide additional attendance data beyond those named representatives. The limitation therefore concerns the absence of broader attendance information, not the absence of a documented corpus count. A further limitation is the heterogeneous nature of the corpus: it combines direct observation, visual documentation of session materials, facilitator and rapporteur records, published reports and transcribed youth contributions for one component, but not full verbatim transcripts for all sessions across both initiatives. Another limitation concerns the use of translated quotations: although they preserve the substantive meaning of the source material, translation may reduce some idiomatic nuance. The empirical boundaries described in Table 1 are therefore central to the interpretation of the findings. Because the analytical audit was consensus-based rather than independent blind double coding, no intercoder reliability coefficient is available. This reporting distinguishes a source-fidelity audit from a formal intercoder reliability assessment, which is a distinct and method-dependent procedure in qualitative research (O’Connor & Joffe, 2020). The study therefore relies on source traceability, a complete category-to-source audit, an auditable decision trail and consensus resolution (Nowell et al., 2017).

5. Conclusions

The analysed deliberations show how participating young people and youth representatives transformed concerns about misinformation, health education, mental-health access, service usability and participation into prioritised recommendations through structured processes. When supported by traceable documentation, low-inference synthesis and documented analytical review, NGT can organise heterogeneous youth contributions into policy-relevant priorities while preserving the limits of qualitative, non-representative evidence (Bowen, 2009; Harvey & Holmes, 2012; McMillan et al., 2016; Sandelowski, 2000, 2010).

Across the two initiatives, health literacy emerged as a relational and institutional capacity rather than as an individual information deficit. Credibility depends on visible source verification and a stronger presence of qualified health professionals in youth digital spaces; learning depends on curricular continuity, peer mediation, socio-emotional competence and multimodal communication; access depends on rapid, confidential and youth-responsive entry routes; and participation depends on permanent feedback and accountability mechanisms. These domains are interdependent: information cannot readily be used when services are functionally inaccessible, and participation loses legitimacy when recommendations cannot be traced to institutional responses. These interpretations are consistent with research on online health credibility (Sbaffi & Rowley, 2017), school-based health literacy (Paakkari & Paakkari, 2012), adolescent mental-health help-seeking (Gulliver et al., 2010; Radez et al., 2021), organisational health literacy (Farmanova et al., 2018), and meaningful participation (Lundy, 2007).

The practical implications therefore concern system design. Public health institutions and digital platforms should co-design recognisable credibility mechanisms with young people and make credentials, evidence and commercial relationships visible, consistent with evidence on web-based health credibility (Sbaffi & Rowley, 2017). Schools should integrate health literacy progressively rather than through isolated sessions (Paakkari & Paakkari, 2012). Health services should reduce procedural and affective friction, especially in mental health, and adapt schedules, language and digital interfaces to youth realities, in line with evidence on help-seeking barriers and adolescent-responsive services (Gulliver et al., 2010; Radez et al., 2021; World Health Organization, 2015). A Youth Health Literacy Council within the National Health Service, or an equivalent structure, could connect recurrent deliberation to monitoring, implementation, and public feedback, consistent with participation frameworks that require audience, influence, and institutional response (Lundy, 2007; World Health Organization, 2021). These policy implications derive from participant priorities and require prospective implementation and evaluation before their effectiveness can be established.

The study contributes empirically by documenting a Portuguese case of youth deliberation in health, conceptually by linking health literacy with trust, agency, usability and governance, and methodologically by showing how a qualitative descriptive orientation can combine synthesis that remains close to the source material with theoretically informed interpretation, provided that analytical stages and evidentiary boundaries are transparent (Sandelowski, 2000, 2010). Its limitations—non-representative participation, heterogeneous documentary materials, incomplete transcripts, translated quotations, consensus-based rather than blind double coding, and the absence of downstream impact assessment—define clear boundaries around the conclusions.

Future research should test the transferability of the five domains with more socio-demographically diverse youth groups, compare deliberative formats, examine how disagreement and minority positions are handled, and follow recommendations prospectively from deliberation to adoption, implementation and evaluation. The central conclusion is that young people should not be positioned solely as recipients of health information. When institutions provide structured, credible and accountable routes for participation, young people can contribute substantive knowledge to the design of more intelligible, accessible and equitable health systems (Lundy, 2007; World Health Organization, 2021).