Integrating health literacy, health promotion, and digital health in tuberculosis prevention: An ecosystemic competency framework and CIMO-based systematic review.

Background and Aim: Tuberculosis (TB) continues to pose a major global public health burden, particularly in low- and middle-income countries. Although biomedical interventions have advanced, prevention remains strongly influenced by behavioral, sociocultural, and systemic determinants. Health literacy, health promotion, and digital health innovations have demonstrated potential in improving TB-related outcomes; however, their integration within a unified theoretical framework remains limited. This study aimed to synthesize evidence on TB prevention strategies by integrating health literacy, health promotion, and digital health using the Ecosystemic Health Promotion Competency Framework (EHPCF) and the Context-Intervention-Mechanism-Outcome (CIMO) approach. Materials and Methods: A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 guidelines. Literature published between 2015 and 2025 was retrieved from the Scopus database using structured keywords related to TB prevention, health literacy, health promotion, and digital health. Of 417 identified records, 49 studies met the inclusion criteria after screening and eligibility assessment. Data extraction was performed using a structured matrix, and thematic synthesis was applied. Study quality was assessed using the Mixed-Methods Appraisal Tool, while the CIMO framework guided analytical interpretation. Results: Health literacy consistently emerged as a significant predictor of preventive behaviors, with 34% of studies focusing on behavior relationships, 32% on determinants, and 28% on interventions. Community-based health promotion interventions improved self-efficacy, awareness, and health-seeking behavior, though long-term sustainability remained insufficiently evaluated. Digital health interventions, including mHealth and eHealth platforms, enhanced awareness and adherence but were constrained by inequitable access and digital divides. Structural and cultural determinants, such as poverty, stigma, and migration, significantly influenced TB prevention outcomes; however, these factors were rarely integrated into intervention models. The CIMO synthesis highlighted that context-specific mechanisms, including trust, social support, and stigma reduction, mediated improvements in preventive behaviors and adherence. Conclusion: This systematic review provides an integrative perspective linking health literacy, health promotion, digital health, and socio-structural determinants in TB prevention. The EHPCF offers a multidimensional competency-based framework, while the CIMO approach enhances understanding of intervention mechanisms across contexts. Future research should prioritize longitudinal and mixed-methods designs, address digital inequities, and validate integrative frameworks to support sustainable TB prevention strategies.