Article Text

Original research
Health literacy among adolescents and young adults in the Eastern Mediterranean region: a scoping review
  1. Mohammed B A Sarhan1,2,
  2. Rika Fujiya1,3,
  3. Junko Kiriya2,
  4. Zin Wai Htay2,4,
  5. Kayono Nakajima2,
  6. Rie Fuse1,
  7. Nao Wakabayashi1,
  8. Masamine Jimba2
  1. 1 Graduate School of Health Management, Keio University, Fujisawa, Kanagawa, Japan
  2. 2 Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
  3. 3 Faculty of Nursing and Medical Care, Keio University, Fujisawa, Kanagawa, Japan
  4. 4 Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
  1. Correspondence to Dr Rika Fujiya; rfujiya{at}sfc.keio.ac.jp

Abstract

Objectives For adolescents and young adults, most health literacy research has been conducted in Western countries, but few studies have been conducted in the Eastern Mediterranean region (EMR). This review aimed to explore the existing health literacy research in the EMR in addition to the levels of health literacy and its associated factors among adolescents and young adults.

Methods The search, conducted using the PubMed/MEDLINE, EBSCOhost/CINAHL plus, Web of Science and J-STAGE databases, was initially performed on 16 June 2022 and later updated on 1 October 2022. Studies that targeted 10–25 years old persons, conducted in any of the EMR countries and that used the health literacy concept and/or described its levels or predictors were included in the review. Content analysis was used for data extraction and analysis. Data related to the study methods, participants, outcome variables and health literacy were extracted.

Results The review included 82 studies, most of which were conducted in Iran and Turkey and adopted a cross-sectional design. Half of the studies showed that more than half of adolescents and young adults had low or moderate health literacy. Nine studies applied university-based or school-based health education interventions to improve health literacy, which was also predicted by demographic and socioeconomic factors and internet usage. Little attention was paid to assessing the health literacy of vulnerable people, such as refugees and those with a disability and exposed to violence. Finally, various health literacy topics were investigated, including nutrition, non-communicable diseases, media and depression.

Conclusion Health literacy levels were low-to-moderate in adolescents and young adults in the EMR. To promote health literacy, it is recommended to use school-based health education and attempt to reach adolescents and young adults through social media platforms. More attention should be paid to refugees, people with disabilities and those exposed to violence.

  • Adolescent
  • Health Education
  • PUBLIC HEALTH

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. Not applicable. All data relevant to the study have been included in the article or uploaded as supplementary information.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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Strengths and limitations of this study

  • This scoping review is the first attempt to identify research on health literacy among adolescents and young adults in the Eastern Mediterranean region using systematic, transparent and replicable methods, similar to the approach followed in conducting systematic reviews.

  • A wide range of differences and variations were detected among the identified studies in terms of quality, methods, scales used and outcomes.

  • The content analysis and narrative approach of this review might have overcome previous limitations and helped gain better insight into health literacy and its predictors in the Eastern Mediterranean region.

  • This review assessed the risk of bias and quality of the studies, although this is not typically required in scoping reviews.

  • In this review, grey literature and conference proceedings were not included, which might be considered a selection bias.

Introduction

Health literacy has been gaining increasing attention since its introduction in the 1970s,1 2 and it is now considered a determinant of health.3–5 Health literacy is the necessary knowledge and skills that enable people to access, understand, evaluate and apply the acquired health information to make appropriate health-related decisions on a daily basis.1 The concept of health literacy has expanded to include cognitive factors which affect motivation and the ability to use the health information gained in the best way.1 6

Health literacy research has recently increased among adolescents and young adults.7 This is because when health literacy strategies and plans are integrated early in life, the possibility of adopting healthy lifestyles will be maximised when individuals grow old8 9; these lifestyles usually include a healthier diet, physical activities and resilience concerning health-related issues. Furthermore, it increases the possibility of good mental and psychological health in adulthood.10–12

Most health literacy research among adolescents and young adults has been conducted in Western countries (North America, Europe and Australia) and mainly addresses the prevalence of limited or low health literacy.13–16 For instance, in the USA, more than 30% of adolescents and young adults had low health literacy.17 In Europe, low and moderate health literacy was reported among 13% and 67% of 15-year-old adolescents in 10 countries (Austria, Belgium, Germany, England, Finland, Estonia, Czech Republic, Macedonia, Poland and Slovakia), respectively.16 In another study conducted in Germany, 47% of 15–29 years old adolescents and young adults had limited perceived health literacy.14 In Australia, adolescents and young adults who survived cancer had good functional and interactive health literacy, but they also reported low critical health literacy.15 However, studies on health literacy in countries in the Eastern Mediterranean region (EMR) are scarce.18

For a long time the EMR has suffered from multiple problems, including unstable states and armed conflicts.19 20 People are facing displacement, insecurities, human rights violations and disruption of their social networks, and these factors cause extensive adverse health consequences.21 In this region, despite the adverse effects of the current unstable health situation, high health literacy can help adolescents and young adults receive better healthcare, prevent disease, promote health and have a better quality of life.1 4 14 Therefore, understanding of health literacy and its predictors in this region is essential for populations, especially adolescents and young adults. This review aimed to explore the existing health literacy research in the EMR in addition to the levels of health literacy and its associated factors among adolescents and young adults.

Methods

This study used a scoping review design that involved assessing the scope of available research on a specific topic. The main objective of a scoping review is to investigate the nature and magnitude of published evidence and identify existing gaps in the literature.22–24

Eligibility criteria

We did not restrict the search by study design, publication year (all studies published from conception until 30 September 2022), or language (the search was limited to published scientific articles with an English title and abstract). The eligibility criteria for this review were as follows: (1) studies targeting adolescents and young adults (10–25 years old) based on the WHO’s definition25 and (2) studies conducted in any of the countries in the EMR defined by the WHO; these countries are Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates (UAE) and Yemen.26 We also considered publications from Algeria, Mauritania, Ethiopia, Eritrea, Israel and Turkey due to the geographical continuity or the contextual and cultural similarities (figure 1) and (3) studies that used the concept of health literacy and described its levels (ie, scores and/or proportions) or predictors regardless of whether health literacy was the primary outcome of the study.

Figure 1

A map showing the countries targeted in this review. (Created with mapchart.net)

Search strategy

We initially searched for relevant articles in the PubMed/MEDLINE, EBSCOhost/CINAHL plus, Web of Science and J-STAGE databases. We used search terms related to health literacy (nutrition literacy, food literacy and medical literacy), age groups (eg, adolescents) and target countries (online supplemental table 1). Subsequently, we searched for potentially relevant studies using Google Scholar and the references of the included articles found in the electronic searches. The first search was performed on 16 June 2022 and later updated on 1 October 2022.

Supplemental material

Process of selecting and identifying studies

Five researchers (MBAS, ZWH, KN, NW and RFus) screened and evaluated the titles and abstracts of the articles found in the search to eliminate irrelevant studies. We obtained the reports of potentially relevant articles and read them for secondary screening. Any disagreements were referred to another researcher for the final judgement.

Data extraction

For eligible articles, content analysis methods were used for data extraction and analysis. Three researchers independently extracted data from the included reports. They mainly extracted data related to the study methods (eg, study design, location of the study and setting), participants (eg, sample size, characteristics (age, sex, other)), outcomes (eg, health literacy or other health-related topics) and other relevant variables. We extracted data related to measurement tools, mean scores and the prevalence of health literacy. All extracted data are presented in tables.

For reports that did not provide the data necessary, we contacted the authors via email. If the authors did not reply within two weeks after sending the email and it was impossible to justify the results without the data, we excluded the report from the review.

Assessment of risk of bias in the included studies

The risk of bias has rarely been evaluated in scoping reviews23; however, we assessed it in the included studies. All authors of this study agreed to use the following tests: (1) Risk Of Bias In Non-randomised Studies of Interventions developed by the Cochrane collaboration,27 (2) the modified version of the Newcastle-Ottawa Scale to assess the risk of bias in cross-sectional studies28 and (3) the Critical Appraisal Skills Programme checklist for qualitative research.29 30

Patient and public involvement

The patients and public were not involved in the design or planning of this study.

Results

We identified 2709 records in the initial search. After removing duplicates, we screened the titles and abstracts of 2246 records and subsequently selected 201 full-text articles. The authors of 14 reports were contacted to obtain additional information; however, we received only three responses to our enquiry, and only one study was included. Eventually, 82 studies were included for further analysis (figure 2).

Figure 2

Flow diagram of search and selection process for studies to be included in the scoping review.

Characteristics of the included studies

All 82 articles were published between 2011 and 2022, and 60 of them have been published since 2020. The largest number of included studies were conducted in Iran (n=32), followed by Turkey (n=28), Jordan (n=5) and Palestine (n=4). The most common study design among the included studies was cross-sectional (n=70), followed by quasi-experimental (n=7), qualitative (n=3) and randomised controlled trials (n=2). Online supplemental table 2 shows the basic characteristics of the included studies.

Education facilities were the most common recruitment settings (school: n=52; and university/college: n=24), followed by households (n=3), clinical settings (n=2), community and public (n=2), social media (n=1) and juvenile detention centres (n=1; online supplemental table 2). The target population comprised individuals aged 10–25 years. One study targeted only young men31 whereas 1o studies included only women.32–41 The other studies included both male and female adolescents and young adults.

Identified outcomes

Forty-nine identified studies had health literacy as the primary outcome. Among these, 12 were mainly concerned with the development or validation of health literacy scales. Other studies used health-related topics, rather than health literacy, as the main outcome; these topics included lifestyle behaviours (dietary habits, food quality and smoking behaviours), body mass index (BMI) status, health-promoting and preventive activities, knowledge and awareness of antibiotic resistance, help-seeking behaviours, health information-seeking behaviours, mental health, oral health, HIV/AIDS risk perception, emergency contraception knowledge, quality of life, self-esteem and self-efficacy during puberty and general health status (online supplemental tables 3 and 4).

Types of health literacy assessed in the included studies

The identified studies used various types of health literacy related to the following health topics: general health31 32 34 35 42–67; nutrition68–82; non-communicable diseases (NCDs)36 63; HIV83 84; e-health39 85–91; media92; physical health93 94; oral health38 95; medical96; disability67 97 98; mental health37 40 41 99–108; suicide109 110; and depression.33 111 These studies used 36 scales to measure health literacy, and these scales can be grouped into three categories: newly developed scales66 77 82 86 93 98; newly adapted and translated scales33 40 41 43 54 55 64 69 83 96 100 111; and previously adapted and translated scales.34 35 38 39 44–46 49 51–53 56–59 62 65 67 68 71–73 76 78–80 85 87–89 91 95 97 103 104 107–110 112 113

Low and moderate levels of health literacy among adolescents and young adults

Half of the studies (n=41) showed that more than 50% of adolescent and young adult participants in the EMR had low or moderate levels of health literacy. General and nutrition-related health literacy were the most common health literacy themes addressed. In Turkey, 12 studies reported problematic or inadequate levels of health literacy among secondary school, high school and university students.45–47 49 53 54 57 63 70 77 79 109 Out of the eight studies conducted in Iran,35 36 46 64 68 70 73 80 one study reported that most high school students had adequate health literacy36 while five reported the opposite.35 46 64 70 73 In the UAE, high school students had a high probability of low health literacy.44 In Egypt, it was reported that two-thirds of non-medical university students had problematic or inadequate health literacy levels,50 whereas in another sample of college students in Jordan, the levels of health literacy were lower than expected.57 Finally, in Palestine, a large proportion of adolescents had low health literacy regarding communication with healthcare providers and confusion about health information, whereas most of them had a high level of functional health literacy.96

Several studies conducted in Saudi Arabia, Iran, Pakistan and Turkey addressing mental health reported a high prevalence of low-to-moderate mental health literacy.41 101–104 107 Regarding specific mental health literacy-related topics, Iranian33 and Saudi37 111 adolescents showed low-to-moderate levels of depression literacy, whereas Lebanese university students showed higher levels of depression literacy, especially when compared with their generalised anxiety disorder literacy. Moreover, the same Lebanese and Jordanian youth reported low levels of suicide literacy and knowledge.108 110 Conversely, Tunisian university students presented a high level of suicide literacy along with high suicide ideation rates.109 Two studies reported that less than 3% of their participants with hearing disabilities had adequate health literacy levels, whereas the remaining participants had inadequate or limited health literacy.97 98

Among the nine studies that addressed e-health literacy,39 85–91 113 a study including Iranian high school students noted a low level of e-health literacy.86 The other six studies were conducted in Turkey: four of them found that Turkish high school and midwifery students had a satisfactory level of e-health literacy39 88–90 whereas the other two found that university and college students had intermediate levels of e-health literacy.85 87 However, low e-health literacy levels have been reported among Turkish children in early adolescence113 and university students.91

Factors associated with health literacy

Demographic and socioeconomic factors

In this review, we identified several demographic and socioeconomic factors associated with health literacy: sex,37 39 42 45 47 49 55 62 63 74 76 90 94 95 101 104 higher income,39 47 51 64 90 97 98 parents’ working status,37 64 68 80 107 occupation,98 age,39 43 49 98 104 113 marital status,98 family type,89 90 ethnicity,44 degree of religiosity107 108 and social security.67 Moreover, health literacy was predicted by the educational level of adolescents, young adults and their parents37 45 47 53 64 68 72 80 89 90 92 95 101; grade at university or school37 39 43 57 67 73 87 95 97 113; years of education98; reading difficulties67; school achievement and academic disciplines57 64 65 70; and parental health literacy.48

Health education

Among the nine studies that used health literacy-related educational interventions,32 34 38 40 56 62 78 83 99 four studies tested the effectiveness of the interventions, with health literacy as the main outcome.38 56 78 83 A study conducted in Tunisia83 used peer-led education to improve HIV-related health literacy, knowledge, risk perception and preventive behaviours. Another study conducted in Turkey,78 provided an 8-hour training programme to adolescents to improve their nutrition literacy; however, this approach was unsuccessful. Another Turkish intervention followed a similar approach among nursing students and was found to be effective, providing 50-minute weekly sessions on health literacy education for four times. Several techniques were used in these sessions, such as narration, question–answer, discussions, the concept map method, case studies and visual tools (eg, computers, projectors and coloured documents), and this intervention increased nursing students’ health literacy.56 Finally, in Iran, an intervention was conducted among adolescents that provided 1-hour educational sessions on oral health literacy four times per week. The curriculum and materials used in this intervention were based on the protection motivation theory.38 This theory-based educational intervention increased oral health literacy and health-related behaviours.

We identified two interventions aimed at improving adolescents’ mental health literacy.40 99 The first was conducted in Ethiopia, and it provided a mental health curriculum in the form of summarised texts, figures and case reports through Facebook and Telegram. The messages were sent every 72 hours (Monday to Friday) for six consecutive weeks.99 This intervention was effective in improving adolescents’ mental health literacy. Another intervention in Iran revealed that the use of a validated mental health curriculum guide was effective in improving female students’ mental health literacy, and it highlights the positive impact of school-based interventions in reducing mental health stigma among students.40

The other three studies incorporated health literacy into the intervention32 34 62; they were all conducted in Iran and used the concepts of health literacy and related skills to improve health-related outcomes. The first study successfully helped university students adopt smoking preventive behaviours by integrating the Health Belief Model and health literacy into educational material delivered through social media platforms (ie, Telegram).62 In addition, using a problem-based learning health literacy approach showed a promising potential in changing health-related behaviours.34 The last study included the provision of health literacy-related theoretical and practical sessions and role-plays. The intervention increased adolescent girls’ self-esteem and self-efficacy during puberty.32

Sources of health information and internet use

To improve adolescents’ health literacy, several studies have recognised the importance of schools,40 42 advisers and lecturers,91 the internet,39 42 53 67 69 72 90 103 113 healthcare professionals,72 103 television72 81 and media literacy (ie, having a better ability to understand and analyse the content of media messages and their hidden purposes),46 taking into consideration the importance of using trustworthy sources and adolescents’ willingness to search for health information.42 72

Health status

Better health status among adolescents and young adults is associated with higher health literacy. Health status includes a wide variety of factors, such as routine health check-ups,45 65 self-perception of health,43 45 48 72 79 107 chronic disease status65 67 and regular medication intake.67 Having a healthcare professional in school was also associated with higher health literacy among adolescents.80 Moreover, mental health predicted health literacy levels and was expressed through various variables such as receiving psychological health services, having mental disorders107 and taking psychology courses.108

Lifestyle and weight status

Awareness about the importance of a healthy lifestyle has been associated with better health literacy.43 48 51 65 For example, sports activities, eating less fast food and reading food labels were associated with higher nutrition literacy in adolescents.79 Furthermore, two studies assessed weight status and BMI as predictors of health literacy.49 70 In the first study conducted in Iran, higher BMI levels in senior high school students were correlated with higher functional nutrition literacy scores; however, this association was not significant after adjusting for the effect of other predictors in the multivariate analysis,70 and the other study in Turkey showed that this association was not significant either.49 In another Turkish study, adolescents who perceived their weight as normal had higher health literacy levels than those who perceived themselves as underweight or overweight/obese.51

Disability

Three studies addressed health literacy in adolescents and young adults with disabilities.67 97 98 The first claimed that auditory and visual problems were not associated with health literacy levels.67 Another reported significantly lower health literacy scores among adolescents who could not hear or expressed having difficulties with hearing—even when using their hearing device—compared with those with no hearing difficulties. Additionally, adolescents who were unable to talk had lower health literacy scores.97 Unlike these two previous studies, another study developed a specific ear and health literacy scale.98 It reported that Iranian adolescents and young adults have poor skills in searching, understanding, evaluating and using health information related to the ear and hearing.

Violence

Among the included studies, only two Palestinian studies addressed the issue of exposure to violence among adolescents.42 60 The first was a qualitative study in which adolescents considered exposure to violence an integral part of their understanding of the concept of health. Moreover, the authors concluded that health literacy might be vital in reducing the negative effects of being exposed to violence and living under chronic conflict conditions.42 This leads to another study evaluating the moderating effect of health literacy on the association between exposure to violence and adolescent weight status.60 It reported that when health literacy levels were higher, lower obesity levels were observed among the Palestinian adolescents who were directly exposed to any form of violence either political violence or domestic and school violence.

COVID-19

Only one included study focused on the COVID-19 pandemic,39 assessing the association between e-health literacy and self-efficacy levels among Turkish midwifery students receiving distance education during the pandemic. The study reported that levels of e-health literacy and self-efficacy were low, especially among younger students. It concluded by recommending educators and policymakers to provide special training to the students to improve their ability to use the online technologies in a way that will increase their health literacy and self-efficacy levels.

Risk of bias in the included studies

Among the 70 studies which used a cross-sectional design, 47 were of good quality and 19 were of satisfactory quality. The quality of four studies was unsatisfactory owing to inappropriate sampling strategies (no clear description of the sampling procedure, no representative sample and unjustified sample size) and inappropriate statistical analyses (online supplemental table 5).31 40 73 84 Regarding the quasi-experimental studies, seven studies were evaluated as having a serious risk of bias, mostly because of confounding factors34 40 62 78 83 99 and the allocation of participants into intervention or control groups.32 34 78 83 Moreover, these studies had a risk of bias in the outcome assessment because the outcome assessors were not blinded to the intervention status (online supplemental table 6).32 34 83 Two randomised controlled trials were evaluated, one of which raised concerns related to missing data and selection of reported results.38 Finally, two42 106 out of the three qualitative studies included in this review were of good quality.

Discussion

We found that adolescents and young adults in the EMR have low-to-moderate levels of health literacy. Their levels of health literacy might be predicted by a wide range of factors, including demographic and socioeconomic factors such as age, sex and education, as well as by school-based health education activities. Moreover, internet use was associated with health literacy levels. However, little or no attention has been paid to the association between disability and exposure to violence and health literacy given the political instability in the region. Finally, many themes related to health literacy were studied, such as nutrition, NCDs, HIV/AIDS, media and medical and depression literacy.

Health literacy level and its associated factors

Half of the studies showed that more than 50% of adolescents and young adults in the EMR had low or moderate levels of health literacy. Similar to our findings, a systematic review targeting health literacy research in Southeast Asian countries reported that, on average, 55.3% of adolescents in these countries had limited health literacy levels.13 This is problematic because lower health literacy will most likely increase the burden of disease on adolescents and young adults in their future life.

Health education held at university, secondary school or high school was identified as a predictor for health literacy. Several health education approaches were used, such as educational sessions, talks or even watching health-related programmes, peer-led education, problem-based education and life skills training; being involved in such activities may positively influence health literacy.13 According to Nutbeam,114 health literacy is the main outcome of health education, which helps improve the awareness of the social, economic and environmental determinants of health. The identified approaches showed the potential to enhance the health literacy of adolescents and young adults; therefore, the concept of health literacy should be incorporated into the curricula and courses of schools and universities.

In this study, health literacy was also predicted by demographic and socioeconomic factors such as age, sex, education, ethnicity and income. Similar results have been reported among adolescents in Southeast Asian countries13 and in another review targeting children and adolescents aged 6–18 years worldwide.115 In the literature, several health literacy models emphasise that these factors act as antecedents of health, along with social and cultural factors.1 116 117 These antecedents are important because of their impact on how people develop, enhance and use health literacy.

However, none of these studies have assessed the association between health literacy and exposure to violence during the political instability, war or conflict and only one study examined the moderating effect of health literacy on the association between exposure to various types of violence and adolescent weight status.60 Moreover, in this review, only one study included refugees or internally displaced people (IDP) in their sample, and none of the included studies assessed refugees’ health literacy.60 This lack of attention towards exposure to violence and refugees and IDP was unexpected, as many countries in the EMR are suffering from political instability, armed conflicts or wars, with millions of people leaving their homes seeking safety. This instability might lead to the collapse of public and health systems and, therefore, the deterioration of health conditions.19 Experiencing violent events at an early age increases the chances of practicing high-risk behaviours,118 and in the case of wars and armed conflicts, exposure to violence is associated with higher risk of developing long-term health complications.119 Health literacy may play a crucial role in alleviating the negative impacts of the unstable conditions on the health outcomes of people, including adolescents and young adults.

Moreover, limited attention has been paid towards health literacy among people with disabilities. Only three studies have addressed this issue; one reported low health literacy levels in people with hearing impairment97; however, people with other types of disabilities, such as physical or intellectual disabilities, have not been targeted in the EMR. According to the WHO, 100 million people (15%) in the EMR live with some form of disability, which has negative implications for affordability and accessibility to healthcare services, including preventive services (eg, routine screening programmes) and the quality of healthcare received.120 121 People with disabilities might need the necessary health literacy skills to give them the autonomy in following a healthy lifestyle and taking care of their own health.

Since 2020, publications on health literacy targeting adolescents and young adults in the EMR have increased significantly. However, in this review, only one study took the COVID-19 pandemic into consideration,39 examining the association between e-health literacy and self-efficacy in university students receiving distance education during the pandemic. Since the pandemic, health literacy has been globally recognised as an important tool in preventing the spread of not only the infection, but also misinformation.122 Educational interventions aimed at strengthening adolescents’ critical health literacy may be necessary for them to access, comprehend and critically appraise pandemic-related content.123 During the pandemic, health literacy is considered a social vaccine that empowers people to follow preventive measures to protect their health and that of everyone else, including people who are vulnerable and at high risk. It can also empower the health authorities to provide the best health services considering the social, political and economic determinants of health.124

Finally, the internet was identified as one of the main sources of health information necessary for better health literacy. In the USA, 92% of adolescents access the internet daily, whereas 71% have at least one social media account.125 In the EMR, social media usage through mobile phones had doubled in the past 5 years reaching 44%, and 9 out of 10 Arab youths use at least one social media platform daily.126 However, research on the association between social media use and health literacy in the EMR was limited. A systematic review showed that social media was more likely to succeed in positively encouraging adolescents and young adults to change their behaviour,127 which indicates that they are an influential tool for the dissemination of health information. Therefore, social media has the potential to generate health literacy if used properly.

Strengths and weaknesses

This review is the first attempt to identify research on health literacy among adolescents and young adults in the EMR. The main strength of this scoping review is that it follows a systematic, transparent and replicable method similar to the approach used in systematic reviews. A wide range of differences and variations was observed between the identified studies in terms of quality, methods, scales used and outcomes. Given that this was a scoping review and considering the heterogeneity of the included studies, it was impossible to conduct a meta-analysis and calculate a pooled estimate of health literacy prevalence or scores. However, the content analysis and narrative approach employed in analysing this study may have overcome this limitation. We conducted an assessment of risk bias and quality of the studies to inform future health literacy research in this region. This study serves as an important foundation for future research and interventions aimed at improving health literacy in adolescents and young adults in the EMR.

This study did not include grey literature and conference proceedings; this may have resulted in missing information about health literacy research. To minimise the risk of missing health literacy studies, the search was not restricted by language or study design, and enquiries addressed to gain further information or clarification about several of the studies under consideration received low response rates. As a result, some potentially eligible studies were excluded.

Quality of the included studies

More than half of the included studies were of good quality while others had issues that might have undermined their quality. The main issue detected in some observational studies was related to confounders as these studies did not present the statistical means they had used to control for any possible confounders. Some studies performed inappropriate statistical analyses, which may have led to improper inferences regarding the relationships between the hypothesised predictors of health literacy.128 Additionally, some studies did not present the sample size, sampling strategies or clear description of the response rate or characteristics of the non-respondents; therefore, the results of studies with sampling bias should be interpreted with caution as their conclusions may be erroneous.129 In quasi-experimental studies, bias due to confounding factors was detected, along with bias in the allocation of participants into intervention or control groups and in measuring the outcome. Additionally, one of the included randomised controlled trials raised some concerns, influencing the quality of evidence from these trials and their conclusions.

Recommendations for future research

  1. A health literacy platform should be established to bring together different stakeholders and promote health literacy in the EMR. Knowledge and experience exchange can occur at the national, regional and international levels via this platform. For example, this can lead to the adoption of a health literacy measuring tool specific to this region, enabling the study of health literacy and comparative assessments between countries. Valuable insights and lessons can be gained from the European Health Literacy Survey project,130 as well as similar efforts have been made in six Asian countries.131

  2. Interventions should be developed to enhance health literacy skills of adolescents and young adults, and it is recommended that they involve adolescents and young adults in the planning, implementation and evaluation of interventions. This ensures that interventions are customised to suit their competencies, needs and preferences.132 It may be effective to develop secondary, high school or university-based health education interventions and programmes. Moreover, it is important to develop internet-based health education programmes and attempt to reach out to adolescents and young adults via social media platforms such as Telegram, Facebook and Twitter to improve their health literacy levels.

  3. Therefore, it is critical to ensure high-quality research in this region. In addition, it is recommended that systematic reviews be conducted with focused objectives on specific areas of health literacy, such as nutrition literacy or scale development. This is necessary for providing evidence to persuade policymakers to include health literacy in their policies.

  4. Future research should also target vulnerable adolescent groups, especially refugees, adolescents with disabilities and those who are exposed to violence. Improving the health literacy of vulnerable adolescents is crucial for them to maintain a good health status despite their complicated living conditions.

Conclusion

Adolescents and young adults showed low-to-moderate levels of health literacy in the EMR. Improved health literacy is likely to help adolescents and young adults embrace a healthy lifestyle, which will eventually help them become healthier adults who can overcome the negative health impacts of the region’s political instability. Any attempts to improve health literacy should start as early as possible, while adolescents continue to develop their health behaviours before the onset of diseases and illnesses in adulthood. This necessitates rapid action to include health literacy in all sectors, particularly health and education. Various indicators can be used to predict health literacy levels, including demographic and socioeconomic features (eg, age, sex and education), health status and lifestyle. Furthermore, as internet use and school-based health education programmes are associated with health literacy levels, it is necessary to employ new health education strategies and social media platforms to increase health literacy among adolescents and young adults. However, attention should be directed towards assessing the health literacy of vulnerable populations, such as refugees, those with disabilities and those exposed to violence, given the political instability in the region.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. Not applicable. All data relevant to the study have been included in the article or uploaded as supplementary information.

Ethics statements

Patient consent for publication

Ethics approval

Not applicable.

References

Supplementary materials

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Footnotes

  • Contributors Design: MBAS, RFuj, JK, ZWH and MJ. Data extraction: MBAS, ZWH, KN, NW and RFus. Data analysis: MBAS, RFuj, ZWH, KN, NW and RFus. Writing the first and final versions of the manuscript: MBAS. Revision of important intellectual content: MBAS, RFuj, JK and MJ. Guarantor: RFuj. All authors have approved the final version of the manuscript for publication.

  • Funding This study was supported by JSPS KAKENHI (Grants No. 19K11045 and 23H03212).

  • Map disclaimer The inclusion of any map (including the depiction of any boundaries therein), or of any geographical or locational reference, does not imply the expression of any opinion whatsoever on the part of BMJ concerning the legal status of any country, territory, jurisdiction or area or of its authorities. Any such expression remains solely that of the relevant source and is not endorsed by BMJ. Maps are provided without any warranty of any kind, either express or implied.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.