Health literacy and its determinants among pregnant women in Portugal

Health literacy is a key determinant of health outcomes and equity, particularly during pregnancy, a period marked by increased information needs and critical health decisions. Despite its importance, data on health literacy among pregnant women in Portugal remain scarce. This study aimed to assess general health literacy levels and their associations with sociodemographic, health-related, and pregnancy-specific factors in a large sample of pregnant women from the district of Viseu, Portugal.

A cross-sectional study was conducted with 886 pregnant women aged 18 years or older, using the validated HLS₁₉-Q12 instrument to measure general health literacy. Data collection occurred between October 2023 and May 2024 using a multimodal approach (online, interview, and paper-based). Health literacy was categorized into four levels and also dichotomized as limited versus not limited. Descriptive statistics, bivariate analyses, and binary logistic regression were performed to identify determinants of limited health literacy.

The mean general health literacy score was 68.3 (SD ± 10.9). A total of 46.7% of participants were classified as having limited health literacy. Among the pregnant women surveyed, 18.8% were born outside Portugal. Of these, 74.7% were classified as having limited health literacy, compared to 40.2% among Portuguese-born participants. Higher prevalence was observed among women aged 18-29, those born outside Portugal, with lower education, in undifferentiated professions, and facing financial hardship. In the final adjusted logistic regression model, which combined variables selected through forward stepwise inclusion with theoretically important covariates entered in a second block, significant predictors of limited health literacy included being born outside Portugal (adjusted OR 2.43; 95% CI: 1.56-3.80), having lower education (up to high school), holding lower-skilled occupations, financial difficulties, and rating current health as equal or worse. Pre-pregnancy Body Mass Index was also negatively associated with health literacy levels, with higher BMI more prevalent among women with limited health literacy. The model showed good discriminatory ability (area under the ROC curve = 0.78).

A considerable proportion of pregnant women demonstrated limited health literacy, particularly among socioeconomically vulnerable and migrant groups. These findings underscore the urgency of adopting antenatal care approaches that are responsive to health literacy needs. Incorporating brief assessments during early prenatal visits, using plain language and visual communication tools, and offering targeted support to high-risk groups may enhance informed decision-making, promote equity, and improve maternal and neonatal outcomes.