INTRODUCTION
Parents of preterm infants often face challenges in understanding and managing their children's complex medical con ditions and procedures. In general, low parental health literacy is associated with poorer child health outcomes (Enlow et al., 2019; Keles et al., 2024; Lawrence et al., 2021; Yin et al., 2012). Parents with lower health literacy may struggle to process and apply medical information, making it difficult to make informed decisions about their child's treatment (Lawrence et al., 2021, Pilcher & Flanders, 2014). This issue is particularly pronounced in neonatal intensive care units (NICUs), where the transition into parenthood can be over-whelming and a significant source of stress, especially for mothers (Fróes et al., 2019; Konukbay et al., 2024). However, tailored support and targeted interventions can help alleviate these challenges (Melnyk et al., 2006; Shaffer et al., 2020).
Health literacy is the ability to understand and effectively use medical information to make informed healthcare decisions (Moon et al., 2024; Park & Kim, 2023). It plays a critical role in how parents of preterm infants manage their child's care (Enlow et al., 2019). Parents with strong health literacy skills are better equipped to communicate with healthcare providers, feel more confident in managing their child's treatment, and parti cipate actively in care (Mackley et al., 2016). However, in the NICU setting, the complexity of medical terminology and procedures can hinder parents’ comprehension, limiting their ability to engage meaningfully in the care process (Mackley et al., 2016). This gap in understanding may lead to poor communication with medical staff, non-adherence to treatment plans, and ultimately, adverse health outcomes for their infants (Lawrence et al., 2021; Pilcher & Flanders, 2014).
Another critical concern is how parents access and evaluate medical information. Many rely on the internet or informal sources instead of consulting healthcare professionals, increasing the risk of exposure to inaccurate or misleading information that could negatively affect their child's care (Benedicta et al., 2020; Crawford, 2014; Kim & Lee, 2016). The ability to assess the credibility of online health information is essential, as misinformation can influence parental decisions and impact the child's deve lopment and well-being (Benedicta et al., 2020; Frey et al., 2023).
Health literacy interventions for parents of preterm infants are essential to addressing these challenges. By improving parental health literacy, such interventions enable parents to better understand their child's medical needs and encourage more active involvement in care, ultimately leading to improved health outcomes (Melnyk et al., 2006; Kim & Lee, 2016; Benedicta et al., 2020; Frey et al., 2023). For instance, Crawford (2014) demonstrated that tailored educational resources, such as the Information for parents of premature infants, helped parents track their child's developmental progress using corrected age. Additionally, structured programs that guide parents toward reliable medical sources—rather than unverified internet content—have been shown to reduce parental stress and improve outcomes for their children (Kim, 2016; Kim, 2011).
Despite the growing recognition of health literacy's importance, most research has focused on the general adult population, with limited attention to the specific needs of parents of preterm infants (Enlow et al., 2019; Mackley et al., 2016). Moreover, many inter ventions fail to fully address the unique challenges faced by these parents and are often confined to specific regions or healthcare systems, limiting their broader applicability. Few studies have thoroughly explored the extent of parental invol vement in such interventions or evaluated their long-term effectiveness (Burney et al., 2024).
Therefore, conducting a systematic review of health literacy interventions specifically tailored for parents of preterm infants is both timely and necessary. This review aims to fill the gaps identified in previous research and to support the development and implementation of effective, targeted interventions that meet the unique needs of this population. In doing so, it seeks to enhance the caregiving environment for preterm infants and empower families to better navigate the complexities of their child's medical care.
1. Literature Search Strategy and Selection Criteria
1) Research question
This systematic review aimed to evaluate the effectiveness of health literacy interventions for parents of preterm infants. The key research questions guiding this review are:
(1) What types of health literacy interventions have been implemented for parents of preterm infants in NICU or postdischarge settings?
(2) How do these interventions impact parental health literacy, self-efficacy, and infant health outcomes?
(3) What are the methodological characteristics and quality of the existing intervention studies in this field?
2. Literature Search Strategy and Selection Criteria
The literature search focused on peer-reviewed articles published between January 2014 and November 2024. The databases searched included PubMed, Embase, CINAHL, the Cochrane Library, and Web of Science.
(“health literacy” OR “health knowledge” OR “medical literacy” OR “health communication” OR “health comprehension” OR “health numeracy”) AND (“NICU” OR “preterm” OR “preterm” OR “premature”).
Notably, the term “intervention” was deliberately excluded to avoid overly narrowing the search. A preliminary test showed that including this term significantly reduced the number of retrieved articles and unintentionally excluded many relevant studies on health literacy interventions that used alternative terms such as “educational program,” “training model,” or “family-centered care.”
The search was conducted between November 1 and November 10, 2024, ensuring the inclusion of the most recent literature.
Two independent researchers (MK and IH) reviewed the retrieved studies separately to minimize bias and ensure a thorough screening process. Any disagreements in study selection were discussed, and if consensus could not be reached, a third researcher was consulted. This rigorous approach helped prevent the unintentional exclusion of relevant studies due to overly restrictive search criteria.
This review focused specifically on evaluating the effectiveness of health literacy interventions through primary research; therefore, systematic reviews and meta-analyses were excluded. While such studies offer valuable synthesized evidence, the primary objective here was to assess the direct impact of individual interventions. Including secondary sources could have introduced redundancy or resulted in an indirect evaluation of intervention effectiveness. Focusing on primary research enabled a more targeted and practical assessment of how these interventions influence health literacy outcomes.
The inclusion and exclusion criteria were as follows:
1) Inclusion criteria
(1) Studies targeting parents of preterm infants or infants admitted to NICUs.
(2) Studies that implemented interventions aimed at improving parental health literacy.
(3) Studies that assessed the effectiveness of interventions using objective indicators (e.g., health literacy scores, parental self-efficacy, or neonatal health outcomes).
3. Literature Collection and Screening Process
This process included identification, screening, eligibility review, and final inclusion (Fig. 1). During the identification stage, 988 articles were retrieved using the selected databases and search terms. In the screening stage, 220 duplicate articles were removed using EndNote software. The eligibility review stage involved examining the titles and abstracts of the remai ning 768 articles. Of these, 470 were excluded for being unrelated to health literacy interventions, 124 for not targeting parents or families of preterm infants, and 116 for being unrelated to health literacy. This process resulted in 58 articles retained for full-text review.
In the full-text review stage, 40 articles were excluded for not reporting measurable outcomes, and 7 were excluded due to unavailability of the full text. No articles were excluded for being in a non-English language. Ultimately, 11 studies were selected for inclusion in this review.
4. Quality of Selected Studies
The quality of the included studies was assessed using a hierarchical framework for evidence-based practice, which categorizes research into 5 levels. Level 1, the highest tier, includes systematic reviews, meta-analyses, and randomized controlled trials (RCTs), representing the most reliable forms of evidence. Level 2 consists of 2-group nonrandomized studies, while level 3 includes 1-group nonrandomized studies. Level 4 comprises single-subject studies and survey research, and level 5 includes case studies, which offer the lowest level of evidence. In this classification system, studies at lower levels (e.g., level 1) are considered to provide stronger evidence. In comparison, those at higher levels (e.g., level 5) are regarded as less robust (Daly et al., 2007).
5. Analytical Method for Selected Studies
To systematically organize data from the included studies, this review employed the PICO framework, which categorizes content according to Participants (P), Intervention (I), Comparison (C), and Outcomes (O) (Table 1). The PICO framework is a widely used tool in evidence-based medicine for structuring clinical questions and facilitating effective literature searches (da Costa Santos et al., 2007).
Table 1.
PICO summary for literature
| No. | Reference | Participants | Intervention | Comparison | Intervention Type | Measurement | Outcome Classification | Results |
|---|---|---|---|---|---|---|---|---|
| 1 | Franck et al. (2019) | Parents of infants born ≤33 wk gestation (N=375 parent-infant pairs) | Mobile technology- enhanced family integrated care (mFICare) | Standard NICU care | Digital-based | Surveys, data collection via mobile app | Parental health literacy, parent stress, competence, self-efficacy | mFICare group showed improved health literacy and confidence |
| 2 | Mohamed et al. (2022) | 60 Mothers of preterm infants (study group: 30, control group: 30) | Maternal partnership discharge program | Standard discharge program | Face-to-face | Pre- and postknowledge scores | Knowledge of preterm care, infant health outcomes | Study group had better knowledge, weight gain, and reduced infection rates |
| 3 | Hirter et al. (2024) | Mothers of preterm infants (N) = 68 COPE, N=73 control) | COPE: 4-phase educational intervention | Standard parental support | Multistage integrated | TOPSE self- efficacy surveys | Maternal self-efficacy, learning & knowledge | COPE improved maternal learning & self-efficacy |
| 4 | Phagdol et al. (2023) | 160 Mothers of preterm infants | mHealth application for preterm home care | No app-based intervention | Digital-based | Knowledge questionnaire (32 items) | Parental knowledge of preterm care | Significant increase in parental knowledge of home care |
| 5 | McCahon et al. (2023) | Parents of neonates (premature or surgically treated) transitioning from hospital to home (N=240) | Optimized educational materials on ROP | Standard follow-up education | Specialized Educational Tools | Pre- and postsurveys on ROP | ROP knowledge, follow-up attendance | Significant improvement in ROP knowledge and follow-up rates |
| 6 | Li et al. (2022) | 116 Mothers of preterm infants | PRECEDE- PROCEED model for discharge education | Standard education approach | Multistage Integrated | Care knowledge, competence assessment | Care knowledge, skills, competence, readmission rates | Improved competence and lower readmission rate |
| 7 | Sandoval-Cuellar et al. (2023) | 130 preterm infants (moderate to late preterm, 34-37 wk gestational age) | Hospital-home intervention with motor development strategies | Standard hospital discharge process | Digital-based | TIMPSI and parental knowledge questionnaire | Infant motor development, parental knowledge | Increased motor development and parental knowledge |
| 8 | Cheng et al. (2018) | 52 Mothers with preterm infants | Preterm infant care learning portfolio | Pre- vs. postintervention comparison | Face-to-face | Pre- and postdischarge questionnaires | Knowledge, skills, maternal confidence | Greater improvement in participation and confidence |
| 9 | Zhang et al. (2024) | 50 Mothers of preterm infants | 3-Month online breastfeeding education via WeChat | Pre- vs. postintervention comparison | Digital-Based | Breastfeeding knowledge questionnaire | Breastfeeding knowledge, attitudes, self-efficacy | Improved breastfeeding knowledge but no change in attitudes |
| 10 | Benzies et al. (2017) | Mothers and their preterm infants (32 to 34 wk gestation) in 10 level II NICUs in Alberta, with 181 dyads per group, totaling 362 participants | Family integrated care model | Standard NICU care | Family- centered care | NICU stay length, clinical outcomes | NICU length of stay, infant health, parental distress | Shorter NICU stays, improved breastfeeding rates, reduced distress |
| 11 | Globus et al. (2016) | Parents of preterm infants hospitalized in a tertiary NICU, with a total of 178 parents (91 preintervention, 87 postintervention) | SMS-based daily medical updates | Pre- vs. postintervention comparison | Digital-based | Pre- and post-SMS implementation surveys | Parental trust, anxiety, satisfaction with medical staff | Increased trust and satisfaction with medical updates |
PICO, Population, Intervention, Comparison, and Outcome; NICU, neonatal intensive care unit; COPE, Creating Opportunities for Parent Empowerment; ROP, retinopathy of prematurity; TOPSE, tool to measure parenting self-efficacy; TIMPSI, test of infant motor performance screening items; SMS, short message services.
PICO framework components:
6. Methodological Quality Assessment
To ensure a rigorous evaluation of the included studies, this review applied different quality assessment tools based on study design. RCTs were assessed using the Physiotherapy Evidence Database (PEDro) Scale, while nonrandomized studies were evaluated using the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) tool.
1) Quality assessment of RCTs
The methodological quality of the 3 RCTs included in this review was evaluated using the PEDro scale. This scale is widely used in healthcare research, particularly physiotherapy, to assess internal validity and the quality of study reporting (Maher et al., 2003). By evaluating key methodological features, the PEDro scale enhances the reliability of systematic reviews (de Morton, 2009). The PEDro scale consists of 11 items, each rated “yes” or “no.” The total score is based on items 2 to 11, with item 1 (eligibility criteria) excluded from the final score.
Key PEDro scale items:
1. Eligibility criteria specification (not included in scoring).
2. Random allocation of subjects.
3. Concealed allocation to intervention groups.
4. Baseline comparability between groups.
5. Blinding of participants.
6. Blinding of therapists.
7. Blinding of assessors.
8. Completeness of outcome data (≥85% reporting).
9. Intention-to-treat analysis.
10. Appropriate statistical comparisons.
11. Reporting of key outcome variability.
The total PEDro score (0-10 points) reflects the methodological quality of an RCT, with scores categorized as follows (Maher et al., 2003):
• 0-3 points: low-quality study.
• 4-5 points: moderate-quality study.
• 6-8 points: high-quality study.
• 9-10 points: very high-quality study.
By applying the PEDro scale, this review ensured that the included RCTs met rigorous methodological standards.
2) Quality assessment of Nonrandomized studies
For the 8 nonrandomized studies, the ROBINS-I tool was used to assess the potential risk of bias. ROBINS-I evaluates bias in observational and nonrandomized intervention studies (Sterne et al., 2016). This tool considers various sources of bias that may arise due to inherent limitations in study design.
ROBINS-I evaluates 7 domains of bias:
1. Bias due to confounding - Whether differences between groups were accounted for.
2. Selection bias - Whether participant selection was appropriate.
3. Classification bias - Whether interventions were properly classified.
4. Deviation from intended intervention - Whether there was compliance with assigned interventions.
5. Missing data bias - The extent and handling of missing data.
6. Measurement bias - Accuracy and reliability of outcome measurement.
7. Reporting bias - Selective reporting of results.
Each domain is rated as having a “low,” “moderate,” “serious,” or “critical” risk of bias. The overall risk of bias for each study is determined by the highest level of risk assigned across any domain.
By applying both the PEDro scale and the ROBINS-I tool, this review ensured a thorough and methodologically sound quality assessment of the included studies, thereby strengthening the reliability of its findings on health literacy interventions for parents of preterm infants.
RESULTS
1. Quality of Selected Studies
Among the 11 studies included in this review, the distribution of quality levels based on the evidence hierarchy was as follows: level I studies accounted for 3 (27.3%), level II studies were the most common, totaling 5 (45.5%), and level III studies accounted for 3 (27.3%) (Table 2).
Table 2.
The classification of evidence level (N=11)
2. Methodological Quality Assessment of Selected Studies
The methodological quality of the 11 selected studies was evaluated using 2 assessment tools: the PEDro scale for 4 RCTs and the ROBINS-I tool for 7 nonrandomized studies. The RCTs received PEDro scores ranging from 6 to 8, indicating a high level of methodological quality (Table 3).
Table 3.
PEDro scale for quality assessment (4 studies)
| Study | PEDro criterion score | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | Total | |
| Phagdol et al. (2023) | Y | Y | Y | N | N | N | Y | Y | Y | Y | 7 |
| Li et al. (2022) | Y | N | Y | N | N | N | Y | Y | Y | Y | 6 |
| Sandoval-Cuellar et al. (2023) | Y | Y | N | Y | N | Y | Y | Y | Y | Y | 8 |
| Benzies et al. (2017) | Y | Y | Y | N | N | Y | Y | Y | Y | Y | 8 |
| Total Y ratings | 4/4 | 3/4 | 3/4 | 1/4 | 0/4 | 2/4 | 4/4 | 4/4 | 4/4 | 4/4 | |
For the nonrandomized studies, the ROBINS-I assessment revealed that most carried a serious risk of bias, primarily due to confounding, missing data, and deviations from the intended interventions. Of the seven nonrandomized studies, 5 were classified as having a “serious” overall risk of bias, while 2 as rated as having a “moderate” risk (Table 4).
Table 4.
Robins-I for quality assessment (7 studies)
| Study | Bias due to confounding | Selection bias | Classification bias | Deviation from intended intervention | Missing data bias | Measurement bias | Reporting bias | Overall risk of bias |
|---|---|---|---|---|---|---|---|---|
| Franck et al. (2019) | Moderate | Moderate | Low | Moderate | Moderate | Low | Low | Moderate |
| Mohamed et al. (2022) | Moderate | Moderate | Low | Moderate | Moderate | Low | Low | Moderate |
| Hirter et al. (2024) | Serious | Serious | Low | Moderate | Moderate | Moderate | Low | Serious |
| McCahon et al. (2023) | Serious | Moderate | Low | Moderate | Moderate | Moderate | Low | Serious |
| Cheng et al. (2018) | Serious | Moderate | Low | Moderate | Moderate | Moderate | Low | Serious |
| Zhang et al. (2024) | Moderate | Serious | Low | Moderate | Moderate | Moderate | Low | Serious |
| Globus et al. (2016) | Serious | Moderate | Low | Moderate | Moderate | Moderate | Low | Serious |
These findings suggest that while the RCTs demonstrated strong methodological rigor, the nonrandomized studies— despite offering valuable insights—had certain limitations due to potential biases. However, considering the complexity of health literacy interventions and the practical challenges of conducting RCTs in this area, the inclusion of both RCTs and well-designed nonrandomized studies provided a more comprehensive evaluation of the effectiveness of health literacy interventions for parents of preterm infants.
3. General Characteristics of Study Participants
A comprehensive review of the 11 selected studies was conducted to examine the characteristics and outcomes of health literacy intervention programs designed for parents of preterm infants. These studies focused on interventions implemented during the critical transition from the NICU or hospital to the home environment, assessing their impact on parental knowledge, confidence, and caregiving abilities.
Participants included parents of preterm infants born at or before 33 weeks of gestation, as well as mothers in both intervention and control groups. Many studies specifically targeted parents navigating the transition to home care following NICU discharge, including those caring for infants who had undergone surgical procedures. Some studies also included parents of infants born between 32 and 34 weeks of gestation, depending on the study design and intervention strategy. While mothers were the primary participants—reflecting their predominant caregiving role—several studies also actively involved fathers, adopting a family-centered approach to support shared caregiving responsibilities.
These studies not only identified common characteristics among parents of preterm infants but also considered diverse demographic backgrounds, socioeconomic conditions, and psychosocial factors that may influence parental engagement in health literacy interventions.
This review underscores the importance of tailoring interventions to address the specific challenges faced by parents of preterm infants—particularly those experiencing high levels of stress, low caregiving confidence, and difficulties in understan ding complex medical information. By ensuring that interventions are personalized and accessible, healthcare providers can more effectively support parents in building the skills and confidence necessary to care for their preterm infants.
4. Types and Effects of Health Literacy Programs
A systematic analysis was conducted to examine the types and effects of health literacy intervention programs for parents of preterm infants. These programs aimed to enhance parental health literacy, increase caregiving confidence, and reduce stress levels during the transition from hospital to home care.
1) Current status of health literacy interventions
The reviewed studies implemented health literacy interventions across various settings, with the goal of increasing parental knowledge, improving awareness of preterm infant care, and supporting psychological well-being. These interventions included digital programs, face-to-face education, and multistage approaches, each tailored to meet diverse parental needs and learning styles.
2) Types of health literacy interventions
(1) Digital-based interventions
Digital interventions offered parents the flexibility to access essential health information anytime and anywhere. Sandoval-Cuellar et al. (2023) developed a mobile app and WhatsApp-based program to help parents monitor motor development and follow-up care. Globus et al. (2016) introduced a short message service (SMS)-based system to facilitate real-time communication between parents and healthcare providers. Similarly, Zhang et al. (2024) implemented a WeChat mini-program for breastfeeding education, enabling parents to engage in continuous, self-paced learning over a 3-month period. These digital tools have proven especially effective for parents with strong digital literacy, providing on-demand access to reliable healthcare information.
(2) Face-to-face education interventions
Face-to-face education involved direct interaction between parents and healthcare professionals, offering personalized guidance and hands-on training. Mohamed et al. (2022) conducted 3 in-person sessions over the course of a month, covering key caregiving topics such as feeding, infection prevention, and sleep management. Cheng et al. (2018) introduced the preterm infant care learning portfolio (PICLP), a structured program designed to help parents develop practical caregiving skills before and after hospital discharge. These in-person interventions fostered trust between parents and healthcare providers and allowed for individualized feedback, making the learning experience more engaging and effective.
(3) Multistage integrated interventions
Multistage interventions were designed to help parents gradually acquire caregiving knowledge and apply it effectively over time. Hirter et al. (2024) implemented the COPE (Creating Opportunities for Parent Empowerment) program, which provided structured learning sessions aimed at building parental confidence and strengthening emotional bonds with their infants. Li et al. (2022) applied the PRECEDE-PROCEED model, establishing a framework for continuous learning and skill development beyond hospital discharge. These interventions emphasized the importance of progressive learning, ensuring that parents acquired knowledge at a manageable pace while actively applying their skills in real-life situations.
(4) Specialized educational tools-based interventions
Specialized educational tools were designed to help parents systematically understand and manage complex medical information. Phagdol et al. (2023) introduced an mHealth application that provided detailed guidance on caring for preterm infants at home, giving parents convenient access to structured and reliable educational resources. Similarly, McCahon et al. (2023) created educational materials and tracking tools for retinopathy of prematurity (ROP), enabling parents to monitor and participate in their child's eye health management. These tools helped bridge knowledge gaps and simplified complex medical concepts, empowering parents to make informed caregiving decisions.
(5) Family-centered approaches
Family-centered care (FCC) emphasized collaboration between parents and healthcare providers, promoting active family involvement in neonatal care. Benzies et al. (2017) developed a FCC model in which parents partnered with healthcare teams to plan and manage their preterm infant's care. Franck et al. (2019) introduced the mobile enhanced Family Intergrated Care (mFICare) program, which combined mobile technology with family-centered approaches to enhance parental engagement and communi cation. These interventions empowered parents by fostering a sense of partnership and shared responsibility in the care of their infants.
3) Effects of health literacy interventions
The impact of health literacy interventions was analyzed across 11 selected studies, with outcomes categorized into 4 key areas.
(1) Improvement in parental health literacy
A primary objective of health literacy interventions was to provide parents with essential knowledge about preterm infant care and ensure they could apply it effectively. Phagdol et al. (2023) found that mobile applications supported continued learning after hospital discharge, reinforcing caregiving practices such as vaccination scheduling and sleep management. Similarly, Franck et al. (2019) demonstrated that the mFICare intervention enabled parents to collaborate with healthcare providers and access real-time medical information, significantly improving both their health literacy and caregiving confidence.
(2) Enhanced psychological stability and self-efficacy
Health literacy interventions not only boosted parental confidence but also reduced stress and anxiety. Hirter et al. (2024) confirmed that the COPE program significantly improved parents’ self-efficacy and emotional well-being, leading to more active participation in infant care. Cheng et al. (2018) found that the PICLP program empowered parents by helping them recognize their own caregiving capabilities. Likewise, Li et al. (2022) reported that an educational intervention based on the PRECEDE-PROCEED model significantly enhanced mothers' self-efficacy and emotional stability. The program also promoted greater parental engagement in infant care and strengthened parent-infant bonding through structured support systems.
(3) Improved health outcomes for preterm infants
Parental education has a significant impact on the health of preterm infants. Mohamed et al. (2022) found that the maternal partnership discharge program enabled mothers to provide more effective care, resulting in greater weight gain, fewer infections, and improved sleep patterns among their infants. Notably, infection rates dropped from 53.3% to 30%, underscoring the positive effect of parental education on neonatal health. Similarly, McCahon et al. (2023) showed that improved educational materials for parents of infants with ROP led to increased parental knowledge (from 60.9% to 91.8%) and higher follow-up attendance (80%, p=0.008). These findings highlight that well-informed parents are more likely to make sound healthcare decisions for their infants.
(4) Keeping parents engaged in infant care
In addition to improved health outcomes, parental education fosters sustained involvement in infant care. Sandoval-Cuellar et al. (2023) reported that the hospital-home intervention (HHI) program, which used a mobile app and WhatsApp messaging, helped parents track their child's development and remain actively engaged in caregiving. Likewise, Globus et al. (2016) introduced a short message service (SMS)-based medical update system in NICUs that enhanced physician accessibility (p=0.002), in creased parental confidence (p=0.001), and improved overall satisfaction (p=0.03). The system also reduced the frequency of parent-initiated calls without increasing staff workload. These findings demonstrate the potential of digital tools to maintain and strengthen parental engagement throughout the caregiving journey.
4) Characteristics of health literacy program facilitators
The success of these interventions largely depended on the expertise and involvement of program facilitators. Healthcare professionals, including physicians and nurses, played a key role in teaching essential caregiving skills and providing con tinuous support before and after discharge. Therapists specia lizing in motor development guided parents in practical care giving techniques, while educational specialists were respon sible for creating customized learning materials focused on building parental confidence and emotional resilience. The collaborative efforts of these facilitators not only improved parental health literacy but also contributed to more favorable long-term health outcomes for preterm infants.
DISCUSSION
This study systematically reviewed the effectiveness of health literacy interventions for parents of preterm infants, confirming that various approaches—including digital programs, face-to-face education, multistage learning models, and specialized educational tools—play a significant role in enhancing parental health literacy, self-efficacy, and emotional well-being. Additionally, these interventions were linked to positive health outcomes for preterm infants, such as improved weight gain, reduced infection rates, and better sleep patterns. By analyzing a range of strategies, this study underscores the importance of developing tailored health literacy programs that address the specific challenges parents face when transitioning from the NICU to home care. Ensuring that these interventions are practical, accessible, and parent-centered can better prepare caregivers with the skills and confidence needed to manage their infant's care effectively.
Most of the reviewed interventions targeted parents navigating the transition from NICU to home, particularly those caring for infants who required surgical procedures or specialized medical support. Participants included parents of infants born at or before 33 weeks of gestation, caregivers preparing for hospital discharge, and families managing complex medical conditions. While many studies focused on mothers as the primary caregivers, some also included fathers and extended family members, emphasizing the value of a family-centered approach. A key finding was that parents with lower health literacy levels often experienced higher levels of stress and anxiety, along with reduced confidence in their caregiving abilities. These challenges were largely attributed to difficulties in understanding medical information and managing their infant's daily care. This highlights the critical need for structured, easy-to-understand educational resources that are tailored to the diverse needs of parents.
The interventions reviewed in this study varied widely in format, including digital tools, face-to-face education, multistage learning models, and family-centered approaches. Digital interventions offered flexibility by allowing parents to access healthcare information at their convenience, even after hospital discharge. For instance, Sandoval-Cuellar et al. (2023) developed a mobile application and WhatsApp-based sup port system to help parents monitor their infant's motor de velopment. Similarly, Zhang et al. (2024) implemented a WeChat mini-program to deliver structured breastfeeding education. While these digital tools effectively increased parental knowledge, their impact on behavioral and emotional aspects of caregiving—such as self-efficacy and breastfeeding rates— was limited. This suggests that digital interventions alone may not be sufficient to drive behavioral change or enhance psychological well-being, highlighting the need for additional support mechanisms.
Face-to-face education provided parents with direct interaction and hands-on learning opportunities, which proved highly effective in enhancing caregiving skills. Mohamed et al. (2022) conducted in-person training sessions on infection prevention, feeding techniques, and discharge preparation, showing that such interventions significantly boosted parental confidence and readiness for home care. Multistage learning models, such as the COPE program examined by Hirter et al. (2024), were particularly effective in helping parents gradually build caregiving competencies while also supporting emotional resilience and strengthening parent-infant bonding. These structured approaches facilitated progressive learning, ensuring that parents could retain and apply information effectively over time.
To evaluate the impact of these interventions, various asses sment methods were employed, including pre- and post-intervention surveys, health literacy tools, parental feedback, and direct observations. Key outcome measures included improvements in parental health literacy, self-efficacy, emotional well-being, and infant health indicators such as weight gain, infection rates, and sleep patterns. McCahon et al. (2023) found that an educational program focused on ROP significantly enhanced parental knowledge and follow-up adherence, underscoring the critical role of parental education in promoting continuity of neonatal care.
Despite the promising benefits of health literacy interventions, several limitations must be acknowledged. First, most of the reviewed studies were conducted in specific geographic regions, which may limit the generalizability of their findings. Second, research on the long-term effects of these interventions is lacking. While short-term improvements in parental confidence and caregiving skills were observed, it remains unclear whether these gains are sustained over time. Third, inconsistencies in how health literacy, self-efficacy, and caregiving abilities were measured across studies made direct comparisons difficult. Although some studies employed validated assessment tools, others used nonstandardized evaluation methods, highlighting the need for more consistent measurement frameworks. Fourth, this review intentionally excluded systematic reviews and meta-analyses to focus solely on primary research. As a result, while the effectiveness of individual interventions was evaluated, broader synthesized evidence from multiple studies was not considered. This exclusion limits insight into the overall effectiveness of health literacy interventions as demonstrated through meta-analyses, suggesting an important direction for future research. Incorporating systematic reviews and meta-analyses in future studies would help strengthen the evidence base and provide a more comprehensive understanding of intervention outcomes.
Some programs, such as the PRECEDE-PROCEED model and the HHI program, were specifically designed to provide ongoing learning opportunities beyond hospital discharge. However, further research is needed to determine whether these structured models lead to sustained improvements in parental caregiving skills over time. Additionally, expanding family-centered approaches that actively engage fathers and other caregivers could enhance overall caregiving capacity and strengthen family support systems.
To maximize the effectiveness of health literacy interventions, it is essential for healthcare professionals and policymakers to integrate these programs into routine neonatal care. Establishing structured educational programs, training healthcare providers to communicate clearly and empathetically with parents, and ensuring that digital resources are accessible can help create a practical and consistent support system for families. By embedding health literacy interventions into both hospital-based and home-based neonatal care, healthcare systems can better equip parents with the knowledge, confidence, and skills needed to provide optimal care for their preterm infants.
CONCLUSION AND RECOMMENDATIONS
Health literacy plays a critical role in empowering parents and improving health outcomes for preterm infants. While interventions such as digital programs, face-to-face education, and structured learning models have demonstrated significant benefits, the real challenge lies in making these resources widely accessible, sustainable, and seamlessly integrated into routine neonatal care.
One-time educational sessions are a valuable starting point, but they are not sufficient. Parents require ongoing, structured support that evolves with their caregiving journey, helping them build the knowledge, confidence, and skills needed over time. Achieving this requires more than well-designed interventions—it demands a strong network of trained healthcare professionals who can provide personalized guidance, as well as consistent funding and infrastructure to support these programs in the long term.
For health literacy interventions to drive meaningful and lasting change, they must be embedded as a core component of neonatal care—not treated as an optional add-on. Healthcare systems and policymakers must prioritize integrating these programs into both hospital and community care settings, ensuring that all parents—regardless of socioeconomic status or digital access—have equal opportunities to learn, receive support, and care for their preterm infants with confidence.
By making health literacy a foundational element of neonatal care, we empower parents, improve outcomes for preterm infants, and foster a healthcare system that values education, accessibility, and comprehensive support for families from the very beginning.
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