Received:16September2021 | Revised:9December2021 | Accepted:18January2022 DOI:10.1111/hex.13450 REVIEW ARTICLE ‘ Seeking a deeper understanding of distributed health ’ literacy : A systematic review Danielle M. Muscat PhD, Post‐Doctoral Research Fellow1 | Danielle Gessler MClinPsych, PhD Candidate2 | Julie Ayre PhD, Post‐Doctoral Research Fellow1 | Ole Norgaard MSc, Public Health Team Leader3 | Iben R. Heuck BaSc, Student Assistant4 | Stefanie Haar MSc, Student Assistant4 | HelleT. Maindal PhD, Professor in Health Promotion4,5 1SydneyHealthLiteracyLab,SydneySchool ofPublicHealth,FacultyofMedicineand Abstract Health,TheUniversityofSydney,Sydney, Background: Previous research suggests that it would be useful to view health Australia literacy as a set of ‘distributed competencies’, which can be found dispersed 2SchoolofPsychology,FacultyofScience,The UniversityofSydney,Sydney,Australia through the individual's social network, rather than an exclusively individual at- 3DanishDiabetesKnowledgeCenter, tribute. However, to date there is no focused exploration of how distributed Education,CopenhagenUniversityHospital, healthliteracyhasbeendefined,conceptualizedorassessedinthepeer‐reviewed StenoDiabetesCenterCopenhagen,Herlev, Denmark literature. 4DepartmentofPublicHealth,Aarhus Aims: This systematic review aimed to explore: (1) definitions and conceptual University,Aarhus,Denmark models of distributed health literacy that are available from the peer‐reviewed 5HealthPromotionResearch,Copenhagen UniversityHospital,StenoDiabetesCenter literature;and(2)howdistributedhealthliteracyhasbeenmeasuredinempirical Copenhagen,Herlev,Denmark research. Methods: We searched MEDLINE, Embase, CINAHL, PsycInfo, Scopus, ERIC and Correspondence DanielleM.Muscat,PhD,Post‐Doctoral WebofScienceusingtruncatedversionsofthekeywords‘literacy’and‘distributed’ ResearchFellow,SydneyHealthLiteracyLab, (within fivewords' distance). We collatedthedefinitions andconceptual models of SydneySchoolofPublicHealth,Facultyof MedicineandHealth,TheUniversityof distributedhealthliteracy,andreportonhowhealthliteracyhasbeenmeasuredin Sydney,NSW2006,Australia. empirical research studies. Findings related to distributed health literacy from in- Email:danielle.muscat@sydney.edu.au cluded manuscriptswere synthesized usingthematic synthesis. Fundinginformation Results: Of the 642 studies screened, 10 were included in this systematic review. None Themajoritywereempiricalmanuscriptsreportingonqualitativeresearchinoneof fivecountries,withtworeviews,oneconceptualanalysisandonequantitativestudy. Edwards' definition of distributed health literacy, which emphasizes the health lit- eracyabilities,skillsandpracticesofothersthatcontributetoanindividual'slevelof health literacy was widely applied in a variety of clinical and geographical settings. However,wedidnotidentifyanyquantitativeinstrumentswhichdirectlymeasured ThisisanopenaccessarticleunderthetermsoftheCreativeCommonsAttributionLicense,whichpermitsuse,distributionandreproductioninanymedium, providedtheoriginalworkisproperlycited. ©2022TheAuthors.HealthExpectationspublishedbyJohnWiley&SonsLtd. 856 | wileyonlinelibrary.com/journal/hex HealthExpectations.2022;25:856–868.MUSCATETAL. | 857 distributed health literacy. There was significant variability in questions used to explore the concept qualitatively, and discrepancies across studies in regard to (a) what constitutes distributed health literacy and what does not (e.g., general social support), and (b) the relationship between distributed health literacy and other constructs (e.g., publichealth literacy). Conclusion: Although there is a widely applied definition of distributed health lit- eracy, our review revealed that the research space would benefit from the devel- opment of the concept, both theoretically for example via conceptual distinctions betweendistributedhealthliteracyandothertypesofsocialsupport,andempirically for examplethrough thedevelopment of aquantitative measurement instrument. PatientorPublicContribution:Thispaperisasystematicreviewanddidnotinvolve patients or thepublic. KEYWORDS distributedhealthliteracy,healthliteracy,socialcontext,socialsupport,systematicreview 1 | INTRODUCTION skills(i.e.,theabilitytointeractwithanddrawuponothersforsup- port)asaspecifictypeofindividualhealthliteracy.6Thisisalsoillu- Health literacy has historically been defined as an observable set strated in the ‘Social support for health’ subscale of the Health ofindividualskillsthatinformhealthactions.Thisindividualfocus LiteracyQuestionnaire.10 is evident, for example, in the definition adopted by the World Otherworkstillhasrecognizedthatanindividual'shealthliteracy Health Organization in 1998—‘the personal, cognitive and social skills are supplemented by those of others (including family, car- skills which determine the ability of individuals to gain access to, ers and health professionals), together contributing to an improve- understand and use information to promote and maintain good ment in individual or collective health outcomes. Edwards et al.7 health’,1 and in newer definitions such as from the International ‘distributed health literacy’ model, for example, argues that while UnionofHealthPromotion,wherehealthliteracyisdefinedasthe individual health literacy may vary within a group, individuals can combination of personal competencies and situational resources overcomepersonaldeficitsinhealthliteracyskillsbycombiningtheir needed for people to access, understand, appraise and use in- efforts.Inthisway,distributedhealthliteracyisaresourcethatmay formationandservicestomakedecisionsabouthealth.Itincludes buffer the adverse impacts of low health literacy.11 Although pre- thecapacitytocommunicate,assertandactuponthesedecisions.2 vious research has provided a broad overview of the intersection It is also clear from health literacy measurement instruments, betweenhealthliteracyandthesocialcontext,6todatethereisno whichtypicallyassessindividualskills,suchasskillsininterpreting focused exploration of how distributed health literacy has been de- nutrition labels(e.g., the NewestVital Sign),3 recognizingmedical fined,conceptualizedorassessedinthepeer‐reviewedliterature,and terms(e.g.,theRapidEstimatreofAdultLiteracyinMedicine),4and noattempttosynthesizetheexistingbodyofresearch.Toprogress health‐relatedreadingandnumeracyskills(e.g.,TestofFunctional this field, this study aims to explore: (1) definitions and conceptual HealthLiteracyinAdults).5 modelsofdistributedhealthliteracythatareavailablefromthepeer‐ However, more recently, the literature has begun to draw at- reviewedliterature;and(2)howdistributedhealthliteracyhasbeen tention to the intersection between health literacy and the social assessedinempiricalresearch(includinginquantitativeandqualita- context, acknowledging that otherindividuals, familiesand commu- tivestudies). nities also play a role in one's health information acquisition, com- prehension and decision‐making.6–9 Most often, social context is modelledasaconstructthatimpactshealthbutisdistinctfromhealth 2 | METHODS literacy. In a recent systematic review, for example, 23 of 34 iden- tified studies represented social context in this way, measuring an 2.1 | Protocol and registration association between health literacy and a social context variable.6 This included, for instance, measuring whether people with lower ThissystematicreviewwasregisteredontheJoannaBriggsInstitute health literacy had more or less social support, social capital and (JBI)SystematicReviewRegisterandisreportedinaccordancewith social engagement compared to those with higher health literacy. the Preferred Reporting Items for Systematic reviews and Meta‐ Alternatively, a smaller number of studies (n=6) positioned social Analyses2020statement.12 13697625, 2022, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hex.13450 by Dublin City University, Wiley Online Library on [16/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License858 | MUSCATETAL. 2.2 | Eligibility criteria questions,targetgroups,methods,settings,recruitmentprocedures, participant demographics, data analysis) and information related to For this review, we included articles published in peer‐reviewed distributed health literacy (definitions, conceptual models, instru- journalsthatspecifically: ments and approaches used to measure distributed health literacy, findings and authors' conclusions). For the purposes of this review, 1. Aimed to develop a new or refined definition or conceptual de- wedidnotseektoobtainorconfirmdatafromstudyinvestigators. scription of distributed health literacy based on theoretical or empiricaldata;or 2. Defined an analysis of distributed health literacy in the meth- 2.6 | Synthesis of results ods;or 3. Reported aspects or processes relating to distributed health lit- Inlinewithourstudyaims,wecollatedthedefinitionsandconceptual eracyintheresults. models of distributed health literacy that were referred to in the included studies, and report on how health literacy has been mea- We excluded other publication types (e.g., dissertations, books, sured in empirical research studies (including quantitative measure- conference abstracts) and articles that suggested exploring dis- menttoolsandqualitativeinterviewguides). tributed health literacy as a future directionif this was not directly In addition, we also synthesized the results from all included relatedtotheaims,methodsorresultsofthemanuscript.Toattain qualitative studies (including systematic reviews of qualitative stu- the widest range of studies, no limits were set for the language or dies) and theoretical manuscripts using thematic synthesis, as de- dateofpublication. scribedbyHardenandThomas.13Wetookaninductiveapproachto findthemes,whichinvolvedfreeline‐by‐linecodingofthefindingsof primary studies and the organization of these ‘free codes’ into 2.3 | Information sources and search strategy themes.Eachstagewasconductedbytwoauthors(D.M.M.andD. G.),withdiscussionandinputfromtheentireauthorshipteam. Thearticlesearchforthisreviewwascompletedon4February2021. The search strategy aimed to find published journal articles on the topicofdistributedhealthliteracyusingatwo‐stepsearchstrategy: 2.7 | Quality appraisal 1. AninitialsearchofMEDLINE,Embase,CINAHL,PsycInfo,Scopus, Full texts selected for retrieval were assessed for quality using ERICandWebofSciencewasundertaken.Keywordsusedwere standardized critical appraisal instruments from the JBI (https:// truncatedversionsof‘literacy’and‘distributed’(withinfivewords' joannabriggs.org/ebp/critical_appraisal_tools). Due to the hetero- distance). Where controlled vocabulary terms (e.g., MeSH) were geneity of the study designs included, three JBI Critical Appraisal availabletheywereapplied.Thefullsearchstrategiesforallda- Toolswereutilizedtoassessstudyquality.Theseappraisaltoolsin- tabases,includinganylimitsused,areincludedinAppendixSA. cludedtheChecklistforQualitativeResearch14(n=6;forexample,‘Is 2. The reference lists of all eligible articles were checked for any therecongruitybetweentheresearchmethodologyandthemethods additionalrelevantstudies. used to collect data?’), the Checklist for Systematic Reviews and Research Synthesis15 (n=3; e.g., ‘Were there methods to minimise errors in data extraction’) and the Checklist for Quasi‐Experimental 2.4 | Study selection process Studies16 (n=1; e.g., ‘Were outcomes measured in a reliable way’). Any disagreements between reviewers (D. G. and I. R. H) were re- Tworeviewers(D.G.andS.H.orD.M.M)independentlyscreened solvedthroughdiscussionwithathirdmemberoftheresearchteam. all titles and abstracts using EPPI‐Reviewer prior to retrieving full texts,whichwereagainindependentlyscreenedbytworeviewersfor eligibility.Anydisagreementsbetweenthereviewerswereresolved 3 | RESULTS throughdiscussionwithathirdmemberoftheresearchteam(O.N. orD.M.M). 3.1 | Study selection Ofthe642studiesscreened,10weredeemedtomeettheinclusion 2.5 | Data collection process and data items criteria for this systematic review after full‐text screening (see Figure 1). The majority of included studies reported on qualitative Tworeviewers(D.G.andS.H.orH.T.M.orD.M.M)independently research (n=6). Other studies reported on quantitative research extracteddatafromincludedpapersusingdataextractiontoolsfrom (secondaryanalysisofdata;n=1),ortooktheformofasystematic the JBI. The data extracted included basic information about the review (n=1), conceptual analysis (n=1) or ‘perspective’ arti- study (author, year of publication, journal), study details (research cle(n=1). 13697625, 2022, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hex.13450 by Dublin City University, Wiley Online Library on [16/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons LicenseMUSCATETAL. | 859 FIGURE 1 Flowdiagramofstudy selection 3.2 | Study characteristics 3.3 | Quality appraisal Table 1 provides summary details of the original research studies Quality appraisal scores can be found inTables S1–S3. Qualitative (qualitative and quantitative) included in this review. Qualitative studies were rated as high quality overall, while the quantitative studiesincludedparticipantswitharangeofhealthconditions(e.g., study and two studies assessed using the checklist for systematic type 2 diabetes, asthma, gestational diabetes, human im- reviews and research synthesis had lower quality ratings, mainly munodeficiency virus [HIV]) and were conducted in five countries, becausekeydetailsofmethodologicalrigourwerenotelucidatedin two of which were with ethnic minority groups.7,17–21 Lorini and thetext(e.g.,detailsaboutdataextraction;criticalappraisal). colleague's22 secondary analysis included quantitative data from Austria,Bulgaria,Greece,PolandandSpain. In addition to the primary studies, Gessler and colleagues23 3.4 | Definitions and conceptual models of conducted a systematic review of qualitative studies that explored distributed health literacy available from the the process of decision‐making and characterized how adolescents peer‐reviewed literature andyoungadultssharehealthcareinformation.Althoughthe14eli- giblestudiesincludedinthereviewdidnotreferspecificallytodis- 3.4.1 | Definitions tributed health literacy, findings were synthesized using this conceptual frame. Bröder and colleagues conducted an iterative In their seminal paper, Edwards and colleagues7 define distributed conceptualanalysisofchildandyouthhealthliteracyandoffereda healthliteracyas‘…thehealthliteracyabilities,skillsandpracticesof target‐group‐centred definition that embodied concepts of dis- othersthatcontributetoanindividual'slevelofhealthliteracy’.This tributedhealthliteracy.24,25 definition was developed from a longitudinal qualitative interview 13697625, 2022, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hex.13450 by Dublin City University, Wiley Online Library on [16/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons LicenseycaretilhtlaehdetubirtsidgnissessaotsehcaorppadnaseidutshcraeserlanigirodedulcnifosliatedyrammuS 1 ELBAT detubirtsidgnissessaotsehcaorppA epytydutS ycaretilhtlaeh sdohteM tnauQ lauQ noitacolydutS noitalupopydutS snoitseuqhcraeserro/dnasmiA rohtuA thguostahtsnoitseuqweivretnidedulcnI evitatilauqlanidutignoL ✓ modgniKdetinU mret‐gnolahtiwgnivilelpoeP foerutan’detubirtsid‘ehtenimaxeoT .latesdrawdE snoitautistahwni‘yfitnediot ygolodohtem noitidnochtlaeh woherolpxednaycaretilhtlaeh 7)5102( ehtybdetroppuserewstnapicitrap lairesgnidulcni( ‐gnolfoegnarahtiwstnapicitrap foslliksroegdelwonk,ycaretilhtlaeh )sweivretni elpoepnowardsnoitidnocmret enilnorofgnihcraesni,.g.e(srehto rof)s(krowtenlaicosriehtnihtiw demrofnignikam,noitamrofni detaler‐ycaretilhtlaehhtiwtroppus htiwgnitacinummocdnasnoisiced sksat ’)slanoisseforphtlaeh erolpxeotsnoitseuqcipotowtdedulcnI sweivretnievitatilauQ ✓ nrehtroN,tcirtsiDotroP 2epythtiwgnivilelpoeP setebaid2epythtiwstneitapodwoH .lateuerbA rof’srotaidemhtlaeh‘foeloreht lagutroP setebaid rofkrowtenlaicosriehtnoward 91)a8102( dnaamhtsahtiwdesongaidelpoep htlaehdeifitnedihtiwtroppus ogyllausuuoyoD(setebaidowtepyt ?sksatdetaler‐ycaretil fi(stisivlacidemehtotdeinapmocca otuoyksaewfI?)mohwyb,sey aniuoyplehotenoemosesoohc uoydluowohw,eussidetaler‐htlaeh lausivaedivorP.)?yhwdnaesoohc srotaidemycaretilhtlaehfo’pam‘ secitcarpdna)nerdlihc;rentrap,.g.e( sevig;snoitatlusnocsdnetta,.g.e( )ecivda evobasA sweivretnievitatilauQ ✓ nrehtroN,tcirtsiDotroP amhtsahtiwdesongaidstludA amhtsahtiwdesongaidstludaodwoH .lateuerbA lagutroP rofkrowtenlaicosriehtnoward 02)b8102( detaler‐ycaretilhtlaehhtiwtroppus ycaretilhtlaehtuognippam,sksat dna,laudividnihcaerofsrotaidem tnemeganam‐fleselbaneyehtwoh ?amhtsatuobaegdelwonkdnaslliks ecneirepxeriehttuobastnapicitrapdeksA sweivretnievitatilauQ ✓ ytisrevinUsuhraA ytironimcinhtenretseW‐noN cinhtenretseW‐nonwoherolpxeoT .lateinayyaD slanoisseforphtlaehtnereffidhtiw kramneD,latipsoH htiwnemowtnangerp htiwnemowtnangerpytironim 71)9102( evieceryehtwohdnarehtehwdna setebaidlanoitatseg ni)MDG(setebaidlanoitatseg tuobasdneirfdnaylimafmorftroppus ‐latipsohehtecneirepxekramneD setebaidlanoitatseghtiwevilotwoh dnaMDGtuobanoitamrofnidesab noitamrofnisihtetargetniyehtwoh ehT.efilyadyreveriehtotni etagitsevniotsawmiayradnoces ycaretilhtlaehybdeyalpeloreht ycaretilhtlaehdetubirtsiddna spuorgsucoF ✓ 860 | MUSCATETAL. 13697625, 2022, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hex.13450 by Dublin City University, Wiley Online Library on [16/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License)deunitnoC( 1 ELBAT detubirtsidgnissessaotsehcaorppA epytydutS ycaretilhtlaeh sdohteM tnauQ lauQ noitacolydutS noitalupopydutS snoitseuqhcraeserro/dnasmiA rohtuA ehttuobasnoitseuqticilpxeeerhtdeksA ,ecnevorPneiBneiD ohwnemowytironimcinhtE lanretamfoerutanehtenimaxeoT .latenniKcM gnirudytinummocdnaylimaffoelor manteiV ro,tnangerpyltnerrucerew neiBneiDniycaretilhtlaeh 12)9102( ylimafruoysiwoH(spuorgsucofrieht srehtomdnargrosrehtom hcihwgnirolpxeybecnevorP enoynaseoD?ybabehthtiwdevlovni nahtregnuoynerdlihcfo fosecruoslamrofnidnalamrof ycnangerpehttuobaecivdauoyevig sraey5ega ytironimcinhtenoitamrofnihtlaeh sgnihterehterA?ybabehtgnivahdna wohdna,tsurtdnasseccanemow tcepxeytinummoc/ylimafruoytaht secruoseresehtnowardnemow )?tnangerperauoyelihwodotuoy ylimafdnalaicosriehtdna riehtylppaotskrowten htlaehfognidnatsrednu htlaehekamdnanoitamrofni snoisiced ruoffosnoitinifedehtdezilautxetnoC puorgsucoF ✓ ,)erytnalB(nrehtuoS elpoepgnuoyevitisop‐VIH detaler‐ycaretilhtlaehtahW orohamawU gnidulcni(snoisnemidycaretilhtlaeh dnasnoissucsid dna)ewgnoliL(lartneC 53–81dega)VIHWLPY( gnuoYodslliksdnaegdelwonk .late erusneot)ycaretilhtlaehdetubirtsid derutcurts‐imes )uzuzM(nrehtroN sraey ni)VIHLPY(VIHhtiwgniviLelpoeP 81)9102( naiwalaMniVIHotssenetairporppa eno‐ot‐eno iwalaM,snoiger ,efilhtiwepocoteriuqeriwalaM laitinisihttahttroperdna,htuoy sweivretni dnalaicosesrevdafolortnocekat otdesusawnoitazilautpecnoc dna,secnatsmucriclatnemnorivne weivretnidnanoissucsidehtpoleved ehtnacwoH?sevilyhtlaehevil ydutsriehtrofsediug skrowemarfycaretilhtlaehgnitsixe dnaevitcaretni,lacitirc,lanoitcnuf( eb)ycaretilhtlaehdetubirtsid cificepsehtetaroprocniotdeifidom ?iwalaMniVIHLPYfosdeen erewatadycaretilhtlaehlevel‐yrtnuoC sisylanayradnoceS ✓ ,airagluB,airtsuA thgienignivilstnargimmI htlaehfoelorehtssessaoT:miA .lateiniroL elbaliavaylcilbupehtmorfdeniatbo atadfo ,eceerG,ynamreG seirtnuocnaeporuE level‐yrtnuocehtsaycaretil 22)0202( yevruSycaretiLhtlaeHnaeporuEtsrif eht,dnalerI ehtgnitciderpnielbairavlacigoloce noatadlevel‐laudividnI.stroper ,sdnalrehteN gnomaseitirapsidhtlaeh ,sutatshtlaehdeviecrep,pihsnezitic niapSdnadnaloP naeporuEtnereffidnistnargimmi ,stibahgnikoms,xednissamydob hcraeseR.seirtnuocnoinU taecnadnettadnaytivitcalacisyhp ycaretilhtlaehehtseoD:noitseuQ gnineercsrecnaclacivrecdnatsaerb htlaehehtecneulfniyrtnuocafo naeporuEehtmorfdetcartxeerew ?stnargimmignomaseitirapsid .tatsoruEfoyevruSweivretnIhtlaeH )RO(oitarsddocificeps‐yrtnuocehT ehtneewtebnoitaicossaehtrof rehtodnapihsnezitic'stnapicitrap tnaveler‐htlaehlaudividni otnideloopsawscitsiretcarahc stceffe‐modnargnisuROyrammus )seunitnoC( MUSCATETAL. | 861 13697625, 2022, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hex.13450 by Dublin City University, Wiley Online Library on [16/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons Licenseand observation study of the development and practice of health literacy in people with long‐term health conditions, and built on previously published general literacy studies. For example, the manuscript references Wagner et al.,26 in the introduction, ac- knowledgingtheircontributioninrecognizingthat‘severalindividuals may each possess only some aspects of literacy, and by combining their efforts, they may function as more fully literate individuals’. Edwards and colleagues7 also refer to Baynham's27 ‘literacy media- tors’(i.e.,peoplewhomaketheirliteracyskillsavailabletoothers,on a formal or informal basis, for them to accomplish specific literacy purposes) as well as Papen's28 application of this concept to the healthcarecontext. Oftheremainingstudiesincludedinthisreview,mostdrewon theworkofEdwardsetal.7asastartingpoint,referringatleastto their definition of distributed health literacy in the introductory manuscripttext.Asmallernumberofstudiescontinuedtoreference Wagner's distributed literacy either alone or in combination with Edward'sdefinitionwhenfirstdefiningtheconcept(e.g.,Uwamahoro etal.).18 Uwamahoro and colleague's18 definition differs from that of Edwardsinthefocuson‘theskillsrequiredtoaccesssocialsupport which entails help to access, evaluate and understand information and make decisions regarding health from people in one's social network’.Theauthorsnotethat,inanHIVcontext,thisincludesthe abilitytodiscloseone'sHIVstatusandtheabilityandwillingnessof peopleinone'ssocialnetworktoofferthesupportneeded. AlthoughBröderetal.25donotdefinedistributedhealthliteracy perse,theypresentanew‘target‐group‐centredhealthliteracyde- finition for children and young people in the results of their manu- script which positions health literacy as ‘a social and relational construct’.Drawingonthefindingsoftheirconceptualanalysis,the authorsacknowledgethatchildrenandyoungpeople'shealthliteracy can be promoted by social structures in a variety of contexts and include ‘Social Health Literacy Assets’ as a conceptual dimension within their definition.25 This includes the social and cultural re- sources one can access via social support structures in the close socialenvironment(family/peer/communitycontext). 3.4.2 | Conceptual models As well as offering a definition of distributed health literacy, Edwards et al.7 also provide a conceptual model known as the ‘SupportedHealthLiteracyPathway’.Themodelidentifiesinterven- tionpointsatwhichpeopleinaparticipant'ssocialnetworkinfluence thatindividual'shealthliteracythrough(1)sharedhealthknowledge; (2) supported skills and practices; (3) supported actions; (4) copro- ducedinformedoptionsand(5)supporteddecisions. Other work has included distributed health literacy as a com- ponentwithinlargermodelsofhealthliteracy.Uwamahoroandcol- leagues forexample,includedistributedhealthliteracyasafeature of both individual and system health literacy in their ‘contextual model’. Interestingly, distributed health literacy and public health )deunitnoC( 1 ELBAT detubirtsidgnissessaotsehcaorppA epytydutS ycaretilhtlaeh sdohteM tnauQ lauQ noitacolydutS noitalupopydutS snoitseuqhcraeserro/dnasmiA rohtuA otdesusawnoisserger‐ateM.sledom foycaretilhtlaehehtrehtehwerolpxe ehtfotrapnialpxedluocyrtnuoca .ytienegoretehseirtnuoc‐neewteb derusaemsawycaretilhtlaeH ,74Q‐UE‐SLHehtgnisuyllacigoloce ehtgnidulcnisrohtuaehthtiw ehtfonoitroporpdnaeulavegareva foseulavhtiwnoitalupopyrtnuoc ’etauqedani‘sadegdujycaretilhtlaeh riehtni’etauqedanirocitamelborp‘ro sisylananoisserger‐atem 862 | MUSCATETAL. 13697625, 2022, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hex.13450 by Dublin City University, Wiley Online Library on [16/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons LicenseMUSCATETAL. | 863 literacy (i.e.the degree to which individuals and groups can obtain, 3.6 | Synthesis of findings related to distributed process, understand, evaluate and act upon information needed to health literacy makepublichealthdecisionsthatbenefitthecommunity;Freedman etal.)8areconsideredseparateconstructsinthemodeldevelopedby Through our thematic synthesis, we identified two themes from Uwamahoroetal.18Thisisinconsistentwithotherstudiesidentified thedata: inourreviewthathaveused‘public’and‘distributed’healthliteracy interchangeably.22 1. Fromsocialsupporttodistributedskillsandpractices 2. Limitednetworkdensityandnon‐supportiveroles 3.5 | How distributed health literacy has been assessed in empirical research 3.6.1 | Theme 1: From social support to distributed skills and practices 3.5.1 | Quantiative measurement Allstudiesidentifiedhealthliteracyasadistributedattribute.How- We did not identify any quantitative measures of distributed ever, the scope of what was included as distributed health literacy healthliteracy.However,Lorinietal.22useddatacollectedfrom varied.Whilesomefocusedondistributedskillsandpractices,others pre‐existingpopulationstudies(EuropeanHealthLiteracySurvey includedmoregeneralformsofsocialsupport. Reports;EuropeanHealthInterviewSurveyofEurostat)toassess Distributedskillsandpractices:Intheirresults,fourstudiesspecifically whether health literacy as the country‐level ecological variable describe a range of health literacy skills and practices that were predicts health disparities among immigrants in different Eur- distributedaroundanindividualbymembersoftheirsocialnetwork. opean Union (EU) countries, including Austria, Bulgaria, Greece, Abreu et al.,19 for example, found that a core network of health PolandandSpain.Here,healthliteracywasmeasuredecologically mediatorsprovidedmosthealthliteracycompetenciesfortheirpar- using the HLS‐EU‐Q47, with the authors including the average ticipants (e.g., preventing exposure to certain environments or pre- value and proportion of the country population with values of ventingsymptoms,helpinginmomentsofcrisisandintakeofquick‐ health literacy judged as ‘inadequate’ or ‘problematic or in- relief medication, understanding and obtaining health information, adequate’ in their meta‐regression analysis.22 Although this ap- seeking online information). In their analysis of qualitative focus proach is arguably less aligned with existing definitions of group data, McKinn et al.21 found that themes aligned with the distributedhealthliteracy,thestudywasincludedastheauthors conceptualization of health literacy by Edwards et al.7 and therein note the aim was to advance ‘understanding of the role of dis- presentedtheirresultsunderfoursubsectionscorrespondingtothe tributedhealthliteracy’. areasofdistributedhealthliteracydescribedbyEdwardsetal.Inthe context of pregnancy and parenthood in the Dien Bien Provence, Vietnam, ethnic minority women drew upon family and social net- 3.5.2 | Qualitative measurement works to share knowledge and understanding, assess and evaluate information, communicate with health professionals and support Of the qualitative studies identified, Edwards and colleagues7 ori- decision‐making. ginallyincludedinterviewquestionsthatsoughttoidentify‘inwhat Using a hybrid process of inductive and deductive coding, situations participants were supported by the health literacy, Gessleretal.23organizedtheirqualitativesynthesisaccordingtothe knowledgeorskillsofothers(e.g.,insearchingforonlineinformation, five steps in Edwards' Supported Health Literacy Pathway Model, making informed decisions and communicating with health profes- findingsupportacrossallthereviewedstudiesfortheapplicationof sionals)’.Sincethen,thenumber,typeanddepthofinterview/focus thismodelintotheAdolescentandYoungAdult(AYA)cancersetting. groupquestionsrelatedtodistributedhealthliteracyhavevaried.See The authors concluded that AYAs develop their health literacy in Table1forexamples. partnership with their families, who support and share knowledge about the health conditionand skills and practices associated with managing the condition, as well as being actively involved in dis- 3.5.3 | Systematic reviews and conceptual analyses cussionswithclinicians,producinginformedoptionsandmakingin- formeddecisions. The systematic reviews and conceptual analyses that we identified Social support: The remaining studies, however, mainly focused on rarely included methods or search strategies specific to distributed familyandsocialnetworksassourcesof‘socialsupport’,ratherthan healthliteracy.Rather,theyadoptedabroadapproachtosearching providing or supplementing a range of health literacy skills. the health literacy literature, framing their results and/or forming Uwamahoro et al.,18 for example, reported that their participants conclusions and definitions of distributed health literacy from the identifiedmeetingotheryoungpeoplelivingwithHIV(e.g.,through analysisoftheirfindings(seeTable2). teenclubsatclinicsandcommunitysupportgroups)asanimportant 13697625, 2022, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hex.13450 by Dublin City University, Wiley Online Library on [16/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons LicensesesylanalautpecnocdnasweivercitametsysdedulcnifosliatedyrammuS 2 ELBAT ycaretilhtlaehdetubirtsidsawwoH ?dedulcni sisehtnysdnasisylanA smrethcraesdnasecruosataD snoitseuqhcraeserro/dnasmiA epytydutS rohtuA :sawemehtlartneca,stluserehtnI krowemarFehtgnisudesylanaerewataD ,ENILDEM,esabmEdehcraeS evitatilauqezisehtnysdnayfitnedioT citametsyS .laterelsseG slliksycaretilhtlaehfonoitubirtsiD‘ atadylraeehtgniruD.dohtem ygetartshcraeS.LHANICdnaofnIcysP ehtdesserddaevahtahtseiduts weiver 32)9102( ,’sdairtnaicinilc–ylimaf‐AYAgnoma atahtdeifitnedisrohtua,sisylana htlaehfotpecnocehtdenibmoc gnitatilicafssecorplanoitcaretni gniwollofehtdedulcnihcihw ehthtiwdengilasemehtfotesbus ylimaffotnemevlovniehthtiwycaretil ninoitapicitrapdnatnemrewopme :semehtbus yawhtaPycaretiLhtlaeHdetroppuS sawycaretilhtlaeh,hcussA.srebmem nignikam‐noisicedderahs egdelwonkhtlaehderahS .1 fossecorpdirbyhaos,ledoM hcraesfoegnardaorbagnisuderutpac dnastludagnuoydnastnecseloda secitcarpdnaslliksdetroppuS .2 sawgnidocevitcudeddnaevitcudni ‐noisicedderahsgnidulcni,smret seilimafrieht noitcadetroppuS .3 atadesylanaotdesu tneitapnoitapicitraptneitap,gnikam snoitpodemrofnidecudorpoC .4 tneitap,ycaretilhtlaeh,tnemevlovni snoisiceddetroppuS .5 dnatnemrewopme,noitacinummoc ylimaF.tnemegagnetneitap saweractneitapnitnemevlovni gnidulcni,smrethcraesybderutpac ,ylimaf,revigerac,rerac,dairt,tnerap rentrapdnagnilbis dedulcnisawycaretilhtlaehdetubirtsiD ybdesukrowemarf’D‘ehtdetpadA smrethcraesdnasecruosatadcificepS s'elpoepgnuoydnas'nerdlihcssucsidoT erutaretiL redörB :ycnednepeD‘:noisnemidehtni )9002(92.latenamhtoR erutaretildeidutseW‘—deificepston dnagnitarobaleybycaretilhtlaeh weiver 42.late dnaserutcurtsrewop htlaehdnasnrettapesaesiD)1(: lanoitacude,seidutsdoohdlihcmorf efilsahtuoydnadoohdlihcgnirolpxe )0202( ’spihsnoitalerlanoitarenegretni cihpargomed)2(,sevitcepsrep yfitnediothcraeserlacigoloicosdna scitsiretcarahceuqinuhtiwsesahp tahtnoitingocerehthguorht dnasrotcaflautxetnoc:snrettap foseitiralucitrapeuqinuerolpxedna sevitcepsrepyranilpicsiditlummorf ycnega‘s'elpoepgnuoydnas'nerdlihc latnempoleved)3(,seitilauqeni foeratahtelpoepgnuoydnanerdlihc denimretedgniebsadedragerebnac esruocefildnanoitazilaicos:egnahc hcraeserycaretilhtlaehrofecnaveler detneserpseitinutroppoehtyb rewop:ycnedneped)4(,evitcepsrep ’ecitcarpdna ,stxetnoclaicostnereffidehtnihtiw lanoitarenegretnidnaserutcurts cimonoceoicosdnacihpargomed :ycarcomed)5(dna,spihsnoitaler ehtsallewsa,secnatsmucric noitapicitrapdnapihsneziticevitca ’secruoserdetubirtsid deifitneditahtdegdelwonkcastluseR erutaretilfoydobdeifitnediehtdesylanA rofhcraes‘otssecorpevitaretinadeilppA noputcelferdnaenimaxe,esylanaoT lautpecnoC .lateredörB ycaretilhtlaehehtdesserddaseiduts stnenopmocdnasetubirttayfitnediot yranilpicsiditlum,tnaveleresylanadna htlaehtnenimorp sisylana 52)0202( sahcus,dlihcehtotesolcsnosrepfo deifitnediehT.ycaretilhtlaehfo ,seidutsdoohdlihcmorferutaretil doohdlihcnisgnidnatsrednuycaretil dnastnerap,srehtom,srevigerac erewstnenopmocdnasetubirtta .’ygoloicosdna,ecneicslanoitacude htuoydna srehcraeser‘tahtdetondna,srehcaet ybdezirogetacdnadetcurtsnoced afostluserehtnowerd‘oslA dnadlihctahtdesoporpevah rieht,scitsiretcarahcriehtgniyfiralc elbaliavafoweivercitametsys ebdluohsycaretilhtlaehtnecseloda noitalerriehtdna,snoitpmussa htlaehfosgnidnatsrednulautpecnoc htobfotcudorpehtsadedrager erewstluseR.rehtohcaesdrawot ’elpoepgnuoydnanerdlihcrofycaretil dnaslliksycaretilhtlaehlaudividni nahguorhtdezisehtnysdnadepuorg ehtnielbaliavasecruoserrosllikseht ybdetatilicafssecorpevitareti eht,yleman—txetnoclaicoslamixorp snoissucsidlacitylanadnaevitcelfer tahtsnoitutitsnirosreep,stluda maethcraeserehtnihtiw ,srehtognomA.tsurtelpoepgnuoy 864 | MUSCATETAL. 13697625, 2022, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hex.13450 by Dublin City University, Wiley Online Library on [16/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons Licensedeterminantofhealthandacopingstrategy.Theirqualitativeanalysis ofdistributedhealthliteracyfocusedonsocialandcommunitynet- worksasassistingyoungpeoplelivingwithHIVto‘breaktheisolation by enabling them to meet others in the same situation’. While the authorsdidnotethatfamilywasalsoasourceofinformationaswell asmaterialandemotionalsupport,thiswasofferedasasinglesen- tenceinamuchlargerdescriptionofsocialsupportandself‐stigmain the ‘distributed health literacy’ theme of their qualitative analysis. Dayyani et al.17 also found that family could be supportive in the contextofwomenwithgestationaldiabetes;themothersofpartici- pantswereoftenhighlightedas‘emotionalsupporters’,sharingtheir own experiences with diabetes. Although one participant described how her partner found health information related to gestational diabetes on her behalf, the qualitative analysis did not elucidate or exploreanyotherdistributedskillsandpractices.Inthediscussionof their manuscript, however, Dayyani et al.17 acknowledged that ‘to haveaccesstohealthliteracyoffriendsandrelations,non‐Western ethnic minority pregnant women with GDM need to have social networkssupportingthem’. 3.6.2 | Theme 2: Limited network density and non‐supportive roles Anumberofstudiesalsonotedtheabsenceofsupportstructuresin their discussion of health literacy. Two studies reported that there werebarrierstodistributedhealthliteracyforsomeoftheirpartici- pants(e.g.,HIV‐relatedstigma)and/orthatsomepeopledidnothave many or any supporters in their health journey.17,18 This was re- inforcedbyAbreuetal.,19whentheydescribedtwoidentitieswith different distributed health literacy ‘profiles’. One profile was ex- emplifiedbywhattheytermed‘anarrativeofminimization’whereby individuals reported a dense network of health literacy mediators. These participants claimed low impact of asthma on their lives and daily routines, easy control of symptoms and avoidance of major crises. They could rely on their primary care physician for instru- mentalsupportandonclosefamilymemberswithasthmatoprovide emotionalandpragmaticsupport(e.g.,relatedtomedicationuse)and alert them to situations that might trigger an asthma attack. The second profile, however, was referred by the authors as ‘one of disruption’,enactedbyintervieweeswhoreliedonarestrictednet- workofcorehealthmediatorsmadeupofformalsourcesofhealth services (clinical interaction or online) used mainly to provide in- formationalsupport.Theydescribedepisodesofcrisisashighlydis- ruptive,participants'difficultiesincontrollingcrisesandtheirfeelings ofstigma.Theseparticipantstendedtohideasthmaandtolookfor alternativeandcomplementarysolutionstocontrolanxiety,demon- stratingareactiveapproachtoasthmamanagement.20 Other studies have identified the disruptive or non‐supportive role that other individuals may play in the acquisition and use of healthliteracyskills.McKinnetal.,21forexample,reportedthatsocial networksandcollectivedecision‐makingattimeshadanegativeef- fect on health behaviours for ethnic minority women in Dien Bien )deunitnoC( 2 ELBAT ycaretilhtlaehdetubirtsidsawwoH ?dedulcni sisehtnysdnasisylanA smrethcraesdnasecruosataD snoitseuqhcraeserro/dnasmiA epytydutS rohtuA ro”evitcelloc“saotderrefersisiht nI.’ycaretilhtlaeh”detubirtsid“ dertnec‐puorg‐tegratagnisoporp nerdlihcrofnoitinifedycaretilhtlaeh tahtetonsrohtua,elpoepgnuoydna lautxetnocdnassendetalereht siycaretilhtlaehfossendeddebme noitinifedsihtfoerocehttadecalp dnalaudividnignizingoceryb nevignihtiwsecruoserdetubirtsid siycaretilhtlaeH.serutcurts yllaicosgniebsaderedisnoc nodetubirtsiddnadeddebme slevellaicosdnaylimaf,laudividni MUSCATETAL. | 865 13697625, 2022, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hex.13450 by Dublin City University, Wiley Online Library on [16/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License866 | MUSCATETAL. Provence,Vietnam.Thisisexemplifiedbytheexperienceofaparti- support; social capital), and avoids previous critiques of health lit- cipant who mentioned that exclusive breastfeeding could be inter- eracy as ‘new wine in old bottles’.30 It may also support more sys- rupted, andweaningcommenced earlierthanadvisedbased onthe tematicliteraturesearchingandhelptoreplacethebroadandvaried preferences of their parents‐in‐law. Uwamahoro et al.18 also noted approaches used to date. More work is also required to delineate that by providing special treatment to the HIV‐positive client (and between the concepts of public health literacy, community health supporting distributed health literacy) at times exposed them to literacy and distributed health literacy; a concept analysis, for ex- stigmaintheprocess.Intheirconceptualanalysis,Bröderetal.24,25 ample,maybeanappropriatemethodtoachievethis. also acknowledge that health literacy can be hindered by social Fromameasurementperspective,thisreviewhighlightstheneed structures, power relationships, societal demands and layers of forquantitativemeasuresofdistributedhealthliteracy.Whilequali- autonomy. tative approaches allow for deep exploration of distributed health literacy as a concept, a quantitative tool would enable quicker as- sessment,helptovalidatetheconstructandunderlyingtheory,and 4 | DISCUSSION facilitate the measurement of change in distributed health literacy over time and/or with the implementation of health literacy inter- Thissystematicreviewaimedtoexplorethewayinwhichdistributed ventions.Aconceptmappingapproachmaybeparticularlyusefulin healthliteracyhasbeendefined,conceptualizedandassessedinthe developing such a measure,31 particularly as measures will need to peer‐reviewedliteraturetodate,andtosynthesizeexistingliterature carefullydelineatebetweengeneralsocialsupportandsupportthat in this field. We identified few studies reporting on the concept to compensatesforindividualhealthliteracyskills.Measuresshouldalso date. Of the included studies, Edwards' definition of distributed seek to capture the distribution of responsibilities among those in- health literacy, which emphasizes the health literacy abilities, skills volvedinsharedhealthliteracypractices.Thiscouldentaillookingat and practices of others that contribute to an individual's level of (a)thesum ofhealth literacy resourcesavailablewithin one'sprox- healthliteracy,waswidelyappliedacrossdifferentclinicalandgeo- imalsocialcontextandcommunity,and(b)howtheseresourcesare graphicalsettings.Fourqualitativestudiesdescribedindetailtheway then used. In interpersonal psychotherapy, an ‘interpersonal in- inwhichindividualsdrawuponfamilyandsocial networkstoshare ventory’ is usedto identify people withina patient'snetwork using knowledge and understanding, assess and evaluate information, concentric circles (closest on the inside).32 We feel that something communicatewithhealthprofessionalsandsupportdecision‐making. similarcouldalsobeappliedinthemeasurementofdistributedhealth Others more simply reported family and friends as sources of in- literacy.Giventhefindingsofthisreview,theremayalsobeutilityin formationaswellasmaterialandemotionalsupport.Togetherwith tryingtocapturepotentiallynonsupportivenetworks,andspecifically discrepancies in the positioning of distributed health literacy in re- analysingdistributedhealthliteracyinthesocialcontextofchildren lationtootherconcepts(e.g.,publichealthliteracy),ourfindingsraise andadolescents. important questions about what is meant by distributed health lit- Finally,ourreviewmakesevidentthatmuchworkintheareaof eracyandwhattheedgesofthatconstructare.Wealsoidentifiedan distributed health literacy has occurred with children and young array of qualitative assessment approaches, but no quantitative in- adults, in developing countries and/or with ethnic‐minority groups. strumentstodirectlymeasuredistributedhealthliteracy. Given the large body of research that exists regarding culture and The findings of this review reinforce the utility of approaching individualist/collectivistorientations,33andtheuniquesocialcontext health literacy as a distributed attribute and not exclusively in- ofchildren,itisunsurprisingthatresearchershavechosentoexplore dividual. However, variation in the way in which ‘distributed health social networks and distributed health literacy in these groups. literacy'wasassessedanddescribedacrossstudiessuggeststhatthis Movingforward,itwouldbeusefultoexplore,compareandcontrast emergingfieldofresearchwouldbenefitfromadditionalconceptual thevalidityofthesesimilarconstructsamongdifferentgroups. clarity.Particularlyimportantistheneedtodifferentiatebetweenthe support that supplements or compensates for individual health lit- eracyskillsandothertypesofsupportthatonemightreceiveontheir 5 | STRENGTHS AND LIMITATIONS health journey (e.g., general social/emotional support). We suggest thatthehistoricalfocusonskillsiskeytothisdefinitionalchallenge, Weadoptedveryfocusedsearchtermsinthisreview,purposefullyin- with a specific emphasis on skills that supplement or bolster the cludingvariantsof‘distributed’asakeyterm.Inthisway,wewouldhave health literacy of the patient. For example, a carer finding health excluded a number of studies that explore the intersection between informationonsomeone'sbehalfwouldrepresentdistributedhealth health literacy and the social context more generally without referring literacy, while having a neighbour with whom to confide in about specificallytotheconceptof‘distributedhealthliteracy’,andbiasedre- challenges of living with a health condition would not. Moving for- sultstowardsstudiespublishedafter2015.However,thismatchesour ward with more defined parameters about what constitutes dis- study aims and avoids duplication of research which has already been tributed health literacy and what does not will expectedly help to done. Our findings are also limited by the small number of identified ensure that the concept offers a unique contribution—boththeore- studies, although they do represent five diverse countries across the ticallyandpractically—overandaboveexistingconcepts(e.g.,social globeandparticipantswithvarioushealthconditions. 13697625, 2022, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hex.13450 by Dublin City University, Wiley Online Library on [16/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons LicenseMUSCATETAL. | 867 Blinding and independent assessments of articles for inclusion 5. ParkerRM,BakerDW,WilliamsMV,NurssJR.Thetestoffunctional andriskofbiasrepresentanimportantstrength.Wesearchedseven health literacy in adults. J Gen Intern Med. 1995;10(10):537‐541. doi:10.1007/BF02640361 databases for relevant studies and checked reference lists to sup- 6. Sentell T, Pitt R, Buchthal OV. Health literacy in a social context: plement our searching, although we acknowledge that not all po- review of quantitative evidence. Health Lit Res Pract. 2017;1(2): tential databases were searched, which may have resulted in some e41‐e70.doi:10.3928/24748307-20170427-01 missedarticles. 7. EdwardsM,WoodF,DaviesM,EdwardsA.‘Distributedhealthlit- eracy’:longitudinalqualitativeanalysisoftherolesofhealthliteracy mediators and social networks of people living with a long‐term health condition. Health Expect. 2015;18(5):1180‐1193. doi:10. 6 | CONCLUSION 1111/hex.12093 8. Freedman DA, Bess KD, Tucker HA, Boyd DL, Tuchman AM, WallstonKA.Publichealthliteracydefined.AmJPrevMed.2009; Although there is a rather widely applied definition of distributed 36(5):446‐451.doi:10.1016/j.amepre.2009.02.001 health literacy, the research space would benefit from additional 9. KendirC,BretonE.Healthliteracy:fromapropertyofindividualsto conceptual clarity. This includes the development of the concept, oneofcommunities.IntJEnvironResPublicHealth.2020;17(5):1601. both theoretically for example via conceptual distinctions between doi:10.3390/ijerph17051601 10. Osborne RH, Batterham RW, Elsworth GR, Hawkins M, distributedhealthliteracyandotherhealthliteracyconcepts,aswell BuchbinderR.Thegroundedpsychometricdevelopmentandinitial asothertypesofsocialsupport,andempiricallyforexample,through validation oftheHealth Literacy Questionnaire (HLQ).BMCPublic the development of one or more quantitative measurement Health.2013;13(1):658.doi:10.1186/1471-2458-13-658 instruments. 11. LeeS‐YD,ArozullahAM,ChoYI.Healthliteracy,socialsupport,and health: a research agenda. Soc Sci Med. 2004;58(7):1309‐1321. doi:10.1016/S0277-9536(03)00329-0 CONFLICT OF INTERESTS 12. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 Theauthorsdeclarethatthereisnoconflictofinterests. statement: an updated guideline for reporting systematic reviews. J Clin Epidemiol. 2021;134:178‐189. doi:10.1016/j.jclinepi.2021. AUTHOR CONTRIBUTIONS 03.001 13. HardenA,ThomasJ.Methodsforthethematicsynthesisofquali- Concept and design: Danielle M.Muscat, HelleT. Maindal, Ole Nor- tativeresearchinsystematicreviews.BMCMedResMethodol.2008; gaard,JulieAyre,DanielleGessler.Acquisition,analysisorinterpreta- 8(1):45.doi:10.1186/1471-2288-8-45 tion of data: All authors. Drafting of the manuscript: Danielle M. 14. Lockwood C, Munn Z, Porritt K. Qualitative research synthesis: Muscat, Julie Ayre and Danielle Gessler. Critical revision of the methodological guidance for systematic reviewers utilizing meta‐ aggregation. Int J Evid Based Healthc. 2015;13(3):179‐187. doi:10. manuscriptforimportantintellectualcontent:Allauthors. 1097/XEB.0000000000000062 15. Aromataris E, Fernandez R, Godfrey CM, Holly C, Khalil H, DATA AVAILABILITY STATEMENT Tungpunkom P. Summarizing systematic reviews: methodological Alldatarelevanttothestudyareincludedinthearticleoruploaded development, conduct and reporting of an umbrella review ap- proach.IntJEvidBasedHealthc.2015;13(3):132‐140.doi:10.1097/ asSupportingInformation. XEB.0000000000000055 16. TufanaruC,MunnZ,AromatarisE,CampbellJ,HoppL.Chapter3: ORCID Systematicreviewsofeffectiveness.In:AromatarisE,MunnZ,eds. DanielleM.Muscat https://orcid.org/0000-0001-6106-6298 Joanna Briggs Institute Reviewer's Manual., The Joanna Briggs Institute; 2017. Available from https://reviewersmanual. 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