JMIR Publications

ABSTRACT

Background:

With the expansion of technology-enabled care, digital health literacy (DHL) has become integral to effective cardiovascular disease (CVD) management. However, quantitative evidence regarding determinants and health outcomes of DHL in CVD populations remains limited and heterogeneous, underscoring the need for comprehensive evidence synthesis.

Objective:

This systematic review and meta-analysis aimed to (1) estimate DHL levels, (2) synthesize factors associated with DHL, and examine DHL-related health outcomes in CVD populations.

Methods:

A systematic review and meta-analysis of DHL in adults with CVD was conducted in accordance with PRISMA 2020 guidelines. PubMed, EMBASE, Cochrane CENTRAL, CINAHL, Scopus, Web of Science, and Google Scholar were searched for peer-reviewed studies published between 2006 and January 31, 2026. Quantitative studies enrolling adults with CVD that reported a measure of DHL were included. Studies focusing exclusively on primary cerebrovascular disease and non-peer-reviewed articles were excluded. Risk of bias (RoB) was assessed using the Appraisal tool for Cross-Sectional Studies tool, Newcastle–Ottawa Scale, RoB 2, and Risk of Bias in Non-randomized Studies of Interventions. Certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation approach. Pooled mean eHealth Literacy Scale (eHEALS) scores were synthesized using a random-effects meta-analysis. Heterogeneity quantified using the I² statistic and 95% prediction intervals.

Results:

Twenty studies involving 8,581 adults with CVD were included. The overall pooled mean eHEALS score was 24.26 (95% confidence interval 21.19–27.32), with substantial heterogeneity (I² = 98.4%; τ² = 15.55; τ =3.94) and a wide 95% prediction interval (14.66–33.85). Lower DHL was consistently associated with older age, lower educational attainment, female sex, limited social support, and less experience with digital technologies. Higher DHL was associated with more favorable health-related outcomes, including health behaviors, better quality of life, and greater use and acceptance of digital health technologies. Subgroup analyses showed no statistically significant differences in DHL by region, disease type, or age group. The certainty of evidence was rated as low to very low, and substantial heterogeneity persisted across analyses.

Conclusions:

Our findings underscore DHL as a foundational capability for digitally supported self-management in CVD care and reveal disparities associated with age and socioeconomic factors. By integrating evidence on DHL levels, associated factors, and DHL related health outcomes in CVD populations, this review provides a more comprehensive, clinically relevant understanding of DHL beyond studies relying on a single instrument (e.g., eHEALS) or examining isolated domains. DHL appears to be a context-dependent competency shaped by broader structural and social determinants. From a clinical and health system perspective, digital health interventions should be accompanied by structured digital inclusion strategies, including routine assessment of DHL and care delivery to patients’ digital capacities. Further longitudinal and interventional studies are warranted to clarify the causal pathways linking DHL to health outcomes in adults with CVD and to incorporate provider- and system-level perspectives beyond individual-level assessments. Clinical Trial: PROSPERO (CRD420251068000); https://www.crd.york.ac.uk/PROSPERO/view/CRD420251068000.