Mobile App Use and Pregnancy Health Literacy: Cross-Sectional Study Using Bayesian Network Analysis

Health literacy is crucial for pregnancy outcomes; yet, 15%-44% of pregnant women have low health literacy, negatively affecting maternal and fetal health. While pregnancy apps are increasingly used to support it, the psychological mechanisms through which they influence behavior remain unclear. Understanding these mechanisms is essential for designing effective interventions. Cognitive load theory (CLT) and the integrated model of cognitive-affective learning with media (ICALM) provide theoretical frameworks for understanding these digital interventions in pregnancy's emotionally intense context.

This study aimed to understand the psychological and social-cognitive pathways through which engagement with pregnancy apps may enhance health literacy and behaviors.

This cross-sectional survey study included 998 pregnant and early postpartum women aged 18-45 years from the United States and analyzed the data using Bayesian Network (BN) modeling informed by CLT and ICALM. Participants were stratified into Pregnancy+ (Royal Philips) users (n=362), other pregnancy app users (n=507), and nonapp users (n=129). We measured digital engagement, emotions, health literacy levels, support levels and sources, and health behaviors, including physical activity, nutrition, and stress management. The BN model underwent systematic refinement through bootstrap resampling (n=1000) to evaluate arc strength, followed by k-fold cross-validation (k=5) to assess model generalizability and predictive performance.

In our study, pregnancy apps improve health literacy or behaviors, but not through direct pathways. Instead, they work through two indirect psychological pathways: (1) digital engagement related to positive emotions, which in turn is related to health literacy and stress management, and (2) digital engagement strengthened support networks, which in turn are related to health literacy. No direct pathways from digital engagement to health literacy or behaviors were retained. Pregnancy+ users demonstrated stronger adherence to these pathways compared with other app users and nonusers, by demonstrating more joyfulness (5.1 vs 4.7; P=.046), elevated support levels (4.1 vs 3.9; P=.03), and higher critical health literacy scores (8.4 vs 8.2 vs 7.7; P<.001). Pregnancy+ users also showed higher engagement frequencies (P<.001) and more frequently cited pregnancy apps as valuable information sources (78% vs 68%, P=.01) compared with users of other pregnancy apps.

This study reveals that pregnancy apps may enhance health literacy by fostering positive emotions and strengthening support networks. This finding challenges assumptions about digital health interventions and demonstrates that apps function as psychological support systems rather than mere information sources. The findings validate CLT and ICALM within pregnancy contexts, showing that emotionally supportive apps reduce irrelevant emotional processing that consumes cognitive capacity, thereby enhancing information retention. For practice, app developers should prioritize emotional support and social connection over content volume, while health care providers should recommend apps that enhance emotional well-being. This study demonstrates BN's value for revealing complex psychological relationships in digital health contexts.