Review Reports - The Role of Family Cohesion and Health Literacy in Parents’ and Adolescents’ Health: A Systematic Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This is an interesting and ambitious systematic review article that seeks to investigate the mediating and moderating role of health literacy in the association between family cohesion and adolescent health outcomes. The study has a clear PRISMA protocol structure, there is also a table with providing a summary of the studies, and there is also a clear outline of the inclusion and exclusion criteria. However, I also believe that the study has several limitations that need to be addressed before the manuscript can be considered further.

First of all, I think that there is a conceptual overreach considering the evidence reviewed. In other words, the study claims to identify mediating and moderating roles of health literacy between family cohesion and health outcomes; however, most of the reviewed evidence is rather cross-sectional and does not, in fact, test for mediation and moderation models. These causal process-like modelling terms do not reflect the content of the reviewed evidence.

The introductory section is rather too short. It does not contain a specific theoretical model or conceptual framework that can adequately explain how these components under study (health literacy, family cohesion, health outcomes) are related.

In terms of the methodology, I have several concerns such as the following:

There is no mention or presentation of quality appraisal of the reviewed studies using standard checklists for cross-sectional data.

The authors have not presented a justification for synthesising different facets of health (oral health, mental health, substance abuse, etc.) under a single narrative.

From my point of view, the inclusion of qualitative and mixed-methods studies is mentioned but their analytic or conceptual contribution is not explained. What can a qualitative study add to the potentially ambitious claim of 'mediating' and 'moderating' factors?

The authors have not provided search strings (i.e., Boolean) to help enhance the replicability of the findings.

Please explain why you excluded grey literature, which could have enhanced the absence of publication bias.

Large parts of the Results' section is devoted to single studies and the Discussion section simply repeats the Results' findings without going into a greater depth in critically integrating the diverse findings, or identifying inconsistencies.

The Conclusions' section advocates for family-centred interventions and policy changes; however, these recommendations are not based on longitudinal or intervention evidence within the review.

I recommend reformulating the Discussion's section using several theoretical 'lens' (i.e., explanations/ theoretical perspectives) and perhaps, providing a conceptual model that summarises graphically the different types of contributing factors.

Author Response

Dear Editor and Reviewers,

We would like to sincerely thank the Editor and the Reviewers for their thorough and constructive comments on our manuscript entitled “The Role of Family Cohesion and Health Literacy in Parents’ and Adolescents’ Health: A Systematic Review.” We greatly appreciate the time and effort devoted to evaluating our work. The comments have been extremely helpful in improving the conceptual clarity, methodological transparency, and overall quality of the manuscript.

Below, we provide a detailed, point-by-point response to each comment. All changes have been incorporated into the revised manuscript, and corresponding sections have been clarified or expanded accordingly.

Reviewer 1

Reviewer’s comment

This is an interesting and ambitious systematic review article that seeks to investigate the mediating and moderating role of health literacy in the association between family cohesion and adolescent health outcomes. The study has a clear PRISMA protocol structure, there is also a table with providing a summary of the studies, and there is also a clear outline of the inclusion and exclusion criteria. However, I also believe that the study has several limitations that need to be addressed before the manuscript can be considered further.

Response

We would like to sincerely thank the Reviewer for the positive evaluation of the manuscript and for acknowledging the clarity of the PRISMA-based methodology, the study selection process, and the presentation of results. We also appreciate the constructive feedback regarding the limitations of the study.

In response to the Reviewer’s comments, we have carefully revised the manuscript to address the identified limitations. Specifically, we strengthened the theoretical framing of the review, clarified the conceptual (non-causal) use of the terms “mediating” and “moderating,” enhanced methodological transparency, and expanded the Discussion and Limitations sections to critically integrate findings and explicitly acknowledge constraints related to study design and evidence gaps. We believe that these revisions have substantially improved the rigor, clarity, and contribution of the manuscript.

First of all, I think that there is a conceptual overreach considering the evidence reviewed. In other words, the study claims to identify mediating and moderating roles of health literacy between family cohesion and health outcomes; however, most of the reviewed evidence is rather cross-sectional and does not, in fact, test for mediation and moderation models. These causal process-like modelling terms do not reflect the content of the reviewed evidence.

Response

We thank the Reviewer for this insightful and important comment. We fully agree that the majority of the included studies do not formally test mediation or moderation models and that causal inferences cannot be drawn from predominantly cross-sectional evidence.

In response, we have carefully revised the manuscript to avoid causal or model-testing interpretations. The terms “mediating” and “moderating” are now explicitly used in a conceptual and descriptive manner, reflecting patterns and proposed mechanisms discussed in the literature rather than empirically tested causal processes. We have clarified this distinction in the Introduction [red lines 86-92], Methods [red lines 118-122], and Discussion [red lines 306-310], sections to ensure that the terminology accurately reflects the nature and strength of the reviewed evidence.

The introductory section is rather too short. It does not contain a specific theoretical model or conceptual framework that can adequately explain how these components under study (health literacy, family cohesion, health outcomes) are related.

Response

We thank the Reviewer for this valuable comment and fully agree that a clearer theoretical and conceptual framing strengthens the contribution of the review. In response, we have expanded the Introduction to incorporate relevant theoretical perspectives that explain how family cohesion and health literacy may jointly influence health outcomes among parents and adolescents.

Specifically, we introduced concepts drawn from family systems theory and the social determinants of health framework to clarify the mechanisms through which family-level dynamics and health literacy interact [red lines 63-78]. This expanded conceptual framing provides a clearer foundation for interpreting the reviewed evidence without implying causal relationships.

There is no mention or presentation of quality appraisal of the reviewed studies using standard checklists for cross-sectional data.

Response

We thank the Reviewer for this important methodological observation. We acknowledge that a formal quality appraisal using standardized checklists was not conducted. In response to this comment, we have now explicitly clarified this methodological decision in the Methods section [red lines 177-185] and discussed it as a limitation of the review.

Given the substantial heterogeneity of the included studies—encompassing cross-sectional, qualitative, and mixed-methods designs—we considered that applying a single standardized appraisal tool would be methodologically inappropriate. Nevertheless, methodological rigor was addressed through strict inclusion criteria and full-text screening procedures, which are now more clearly described.

The authors have not presented a justification for synthesising different facets of health (oral health, mental health, substance abuse, etc.) under a single narrative.

Response

We thank the Reviewer for this important comment and agree that the rationale for synthesizing diverse health outcomes required clearer justification. In response, we have revised the manuscript to explicitly explain why different facets of health were examined within a single narrative framework.

Specifically, we clarify that oral health, mental health, substance use, and preventive behaviors were synthesized under a broader family-centered public health perspective, as these outcomes are influenced by shared family-level processes and health literacy mechanisms. This rationale has now been clearly articulated in the Methods [red lines 129-134].

From my point of view, the inclusion of qualitative and mixed-methods studies is mentioned but their analytic or conceptual contribution is not explained. What can a qualitative study add to the potentially ambitious claim of 'mediating' and 'moderating' factors?

Response

We thank the Reviewer for this thoughtful and important comment. We fully agree that qualitative and mixed-methods studies cannot provide statistical evidence for mediation or moderation effects. In response, we have revised the manuscript to clearly distinguish the analytic contribution of qualitative evidence from causal or model-testing claims.

Specifically, we clarify that qualitative and mixed-methods studies were included [red lines 123-128] to provide contextual and conceptual insights into family processes , communication patterns, and mechanisms through which family cohesion and health literacy are experienced and enacted in everyday life [red lines 327-334]. Their contribution is therefore interpretative and explanatory, rather than inferential, and supports the conceptual framing of proposed pathways without implying causal mediation or moderation.

The authors have not provided search strings (i.e., Boolean) to help enhance the replicability of the findings.

Response

We thank the Reviewer for this important comment regarding transparency and replicability. We agree that providing the Boolean search strings enhances the methodological rigor of the review.

In response, we have revised the manuscript to include the full Boolean search strategy directly within the Search Strategy [red lines 141-151] section of the Methods, allowing readers to clearly understand and replicate the literature search process.

Please explain why you excluded grey literature, which could have enhanced the absence of publication bias.

Response

We thank the Reviewer for this important comment. Grey literature was excluded to ensure methodological rigor and consistency by focusing exclusively on peer-reviewed studies. We acknowledge that the exclusion of grey literature may increase the risk of publication bias, and this limitation has now been explicitly stated in the manuscript [red lines 159-160].

Large parts of the Results' section is devoted to single studies and the Discussion section simply repeats the Results' findings without going into a greater depth in critically integrating the diverse findings, or identifying inconsistencies.

Response

We thank the Reviewer for this constructive comment. In response, we have revised the Results [red lines 281-282] and Discussion [red lines 299-305] sections to reduce study-by-study descriptions and strengthen the integrative and critical synthesis of the findings. The Discussion has been restructured to emphasize cross-study patterns, highlight areas of convergence and inconsistency, and interpret the findings within a broader conceptual context rather than restating the Results.

The Conclusions' section advocates for family-centered interventions and policy changes; however, these recommendations are not based on longitudinal or intervention evidence within the review.

Response

We thank the Reviewer for this important comment. We agree that the conclusions should accurately reflect the nature of the available evidence. In response, we have revised the Conclusions section [red lines 374-375 and 377-379] to frame recommendations for family-centered interventions and policy directions as implications informed by observed associations rather than as evidence-based intervention effects. We also explicitly acknowledge the absence of longitudinal and intervention studies within the reviewed literature.

I recommend reformulating the Discussion's section using several theoretical 'lens' (i.e., explanations/ theoretical perspectives) and perhaps, providing a conceptual model that summarizes graphically the different types of contributing factors.

Response

We thank the Reviewer for this constructive and forward-looking suggestion. In response, we have revised the Discussion to more explicitly frame the interpretation of findings through complementary theoretical perspectives, without substantially expanding the section. Additionally, we have included a concise conceptual model that graphically summarizes the key contributing factors and their interrelationships, as derived from the reviewed evidence [red lines 286-297].

Reviewer 2 Report

Comments and Suggestions for Authors

The paper implements a systematic literature review discussing the role of family cohesion and health literacy in parents' and adolescents' health.

The main issue in my view is the limited time frame used to find papers that would be eligible for the research - starts in 2017 and ends in 2024. I am not sure as to why there is this time limitation. It would be important to check if there are more papers that discuss this topic using a wider time frame. Include from 2010 to 2025.

A second issue is why scopus and web of science and pubmed are not in the databases employed in the search? If the focus is on articles published on the theme these databases seem to be the best place to perform searches.

Why look at papers published in English and Greek? Is the focus on Greece? Or on studies applied to the Greek context? No. There are studies for various countries. Should you also include their languages as well to include all possible papers?

I think the results are presented in a satisfactory way, as there are tables summarizing information and the text is clear.

The discussion section is also fine. However, in the first paragraph, where the results are said to align with previous literature, please include citations for the specific studies you are referencing. (These findings are in line with previous literature... lines 221-222).

The paper mentions the lack of longitudinal papers that allow for causal effects. Why is this the case? Provide more information on the gaps on the literature.

Overall, it is an important paper with important discussions.

Author Response

Dear Editor and Reviewers,

Reviewer 2

Reviewer’s comment

The main issue in my view is the limited time frame used to find papers that would be eligible for the research - starts in 2017 and ends in 2024. I am not sure as to why there is this time limitation. It would be important to check if there are more papers that discuss this topic using a wider time frame. Include from 2010 to 2025.

Response

We thank the Reviewer for this insightful and important comment regarding the time frame of the literature search. We fully agree that extending the search period strengthens the comprehensiveness and robustness of the review.

In response, we expanded the search time frame to include studies published between January 2010 and March 2025. This revision ensures broader coverage of the existing literature and enhances confidence that relevant evidence was not overlooked. The updated time frame has been clearly reported in the Abstract (green lines 19–20), Inclusion and Exclusion Criteria (Table 1, green line 120), and Search Strategy section (green lines 154–157).

A second issue is why Scopus and web of science and PubMed are not in the databases employed in the search? If the focus is on articles published on the theme these databases seem to be the best place to perform searches.

Response

We thank the Reviewer for this important comment regarding database selection. We agree that Scopus and Web of Science are major multidisciplinary databases and are commonly used in systematic reviews.

In the present review, PubMed was prioritized due to its extensive coverage of peer-reviewed biomedical, public health, and epidemiological journals, which substantially overlap with public health–focused journals indexed in multidisciplinary databases such as Scopus and Web of Science. Given the specific focus of the review on health literacy, family cohesion, and adolescent health outcomes, we considered this approach sufficient to capture the relevant literature.

This rationale has now been explicitly clarified in the Methods section to enhance transparency (green lines 158–161).

Why look at papers published in English and Greek? Is the focus on Greece? Or on studies applied to the Greek context? No. There are studies for various countries. Should you also include their languages as well to include all possible papers?

Response

We thank the Reviewer for raising this point. We agree that language restrictions require clear justification to avoid misconceptions regarding the scope of the review.

In response, we clarified that the inclusion of English and Greek language publications was based on methodological considerations and language proficiency, rather than a focus on a specific national or cultural context. This clarification has been added to the Search Strategy section (green lines 154–155) to ensure transparency.

The discussion section is also fine. However, in the first paragraph, where the results are said to align with previous literature, please include citations for the specific studies you are referencing. (These findings are in line with previous literature... lines 221-222).

Response

We thank the Reviewer for this valuable observation. We agree that explicit citation of relevant studies strengthens the interpretation of the findings and situates the results more clearly within the existing body of literature.

In response, additional references have been incorporated into the Discussion section to support statements regarding consistency with previous research (green lines 315–317).

The paper mentions the lack of longitudinal papers that allow for causal effects. Why is this the case? Provide more information on the gaps on the literature.

Response

We thank the Reviewer for this insightful comment. The scarcity of longitudinal studies in this area likely reflects both methodological and practical challenges inherent in studying family processes, health literacy, and adolescent health outcomes over time. Longitudinal designs require extended follow-up periods, substantial resources, and repeated measurements of family- and literacy-related constructs, which are often complex and context-dependent.

In addition, much of the existing literature on health literacy and family cohesion has emerged within cross-sectional public health and school-based research traditions, where feasibility considerations and large population samples are prioritized. We have now expanded the Discussion section to more explicitly describe these gaps in the literature and to highlight the need for longitudinal and intervention-based research to clarify temporal ordering and potential causal pathways (green lines 356–368).

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors have done an excellent job in addressing my initial concerns. I have no further feedback to offer, considering the nature of the substantial revisions that have been implemented.

Wishing you a swift publication!

Author Response

Comment: The authors have done an excellent job in addressing my initial concerns. I have no further feedback to offer, considering the nature of the substantial revisions that have been implemented. Wishing you a swift publication!

Response: We sincerely thank the reviewer for the positive evaluation of our revised manuscript and for the constructive feedback provided during the earlier review rounds. We are pleased that the revisions adequately addressed the initial concerns, and we appreciate the reviewer’s encouraging comments and kind wishes for publication.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear author(s)

My primary worry is the potential omission of significant papers from Scopus or WoS that are not available in PubMed. You should at least verify.

Overall the theme is important and the paper is well executed.

Author Response

Comment: My primary worry is the potential omission of significant papers from Scopus or Web of Science that are not available in PubMed. You should at least verify. Overall the theme is important and the paper is well executed.

Response: We thank the Reviewer for this important comment and for the positive assessment of the relevance and execution of the manuscript. We fully acknowledge the Reviewer’s concern regarding the potential omission of relevant studies indexed in Scopus or Web of Science but not available in PubMed. In response to this suggestion, we conducted an additional targeted verification search in both Scopus and Web of Science. This supplementary search applied the same core search terms, inclusion and exclusion criteria, and screening procedures as those used in the original search strategy. This verification process did not identify any additional eligible studies that were not already captured through PubMed and the other databases included in the review. Records retrieved from Scopus and Web of Science were either duplicates of studies already included in the review or did not meet the predefined inclusion criteria. We therefore believe that the original database selection, complemented by this additional verification step, provides comprehensive coverage of the relevant literature on health literacy, family cohesion, and adolescent health outcomes. We are grateful to the Reviewer for this suggestion, which allowed us to further confirm the robustness and completeness of the review process. Additionally, the consistency of findings across databases further supports the completeness of the evidence base synthesized in this review.