The World Health Organization defines “health literacy” as “the personal characteristics and social resources needed for individuals and communities to access, understand, appraise, and use information and services to make decisions about health” [1
]. Thus, on the one hand, individuals with adequate health literacy levels are better equipped to manage their health and the health of their families and communities [2
]. On the other hand, low health literacy is associated with lower use of health services [3
], increased medical costs [5
], and low self-rated general health [6
], as well as social disadvantage (such as low income and education levels), where disadvantage is known to contribute to poorer health outcomes at all ages [7
Excellent health literacy requires being able to read, write, fill out forms, and comprehend health information, all necessary skills to understand health-related materials and to act efficiently in different situations [8
]. The ability to interpret, filter, judge, and evaluate health information is also critical [8
]. Adolescent and young adult years are critical for the development of social, emotional, and cognitive skills that are necessary to have autonomy over health and to establishing healthy patterns of behavior over the life-course [9
]. Adequate health literacy during these years can help reduce environmental and interpersonal barriers that young people often face when interacting with health systems [9
]. As recognized by others [8
], little is known about health literacy during adolescence and this knowledge gap is particularly acute in low- and middle-income countries. Moreover, there is a particular need for research that examines predictors of health literacy in adolescence [9
]; identification of adolescent-specific predictors of health literacy requires comparison with other age groups.
Among young populations, low sexual and reproductive health literacy is associated with unintended pregnancies which are, in turn, associated with adverse social and health outcomes for the mother and the child [11
]. Worldwide, 11% of all pregnancies are among adolescents aged 15–19 years, and about 95% of these pregnancies occur in low- and middle-income countries [12
]. The higher rates of adolescent fertility among less advantaged populations may indicate, among other issues, a lack of knowledge about contraception, lack of access to care, or an inability to navigate health services, as well as limited knowledge of the effects of pregnancy and childbirth at younger ages on health-related outcomes [13
Despite some studies [11
] that have investigated the level of sexual and reproductive health literacy among pregnant adolescents, to date, as far as we know, there has not been a study that has assessed the level of general health literacy in this population. Higher health literacy is associated with positive health behaviors in adolescents, including lower use of harmful and addictive substances [18
]. Thus, it is likely that higher levels of health literacy among pregnant adolescents are associated with more positive health behaviors during pregnancy and may help to reduce the adverse health-related outcomes associated with pregnancy and childbirth among this population. The aim of this study was to assess the health literacy of young pregnant adolescents (ages 13–18 years) and a comparable group of young pregnant adults (ages 23–28 years) from a rural area in Northeast Brazil and to examine associated factors, such as socioeconomic conditions, adequacy of prenatal care, and social support from family and friends.
Sample characteristics are presented in Table 1
. Compared to pregnant adolescents, adult pregnant women were more likely to have higher compliance with the national recommendations for adequate prenatal care (61.54% vs. 38.46%), and greater social support from parents (82.2% vs. 61.0%) and friends (75.6% vs. 48.8%). No significant differences were observed between adults and adolescents for race/color, self-perceived school performance as compared with peers, income sufficiency, receiving Bolsa Família, number of prenatal consultations, and social support from grandparents, partner or siblings.
Seventy-three percent of the sample (N = 63) had inadequate health literacy. A significantly higher proportion of adolescents (N = 39, 95.1%) presented inadequate health literacy as compared with adults (N = 24, 53.3%). Table 2
presents the association among the independent variables and health literacy. The proportion of pregnant women who reported average/low school performance as compared with peers, received Bolsa Família, and reported low/no social support of parents was significantly higher among participants with inadequate health literacy. No statistically significant differences were found among health literacy groups in relation to race, income sufficiency, number of prenatal consultations, and social support from friends, grandparents, partners and siblings.
The median SAHLPA-18 score was 10.5 (range 7–15). Adult pregnant women had higher median scores than adolescents (Table 2
). Similarly, pregnant women with self-perceived school performance better than average obtained a higher score than those reporting school performance as average/low. The median SAHLPA-18 score was significantly higher among pregnant women who reported having suitable income as compared with those that reported having either a very high or very low income. The median score among participants reporting not receiving Bolsa Família was significantly higher than those reporting receiving it. There was no significant difference in median score by type of social support. However, a marginally higher median score was observed for pregnant women who had high social support of parents as compared with those with low parental support (p
= 0.052) Appendix A
shows the comparisons of SAHLPA scores between adolescents and adults for all categories of the independent variables (Table A1
). Significantly lower SAHLPA scores were observed for adolescents in almost all categories, showing that pregnant adolescents presented poorer health literacy than pregnant adults in most socioeconomic subgroups.
Women with adequate health literacy also presented higher compliance with recommendations for an adequate prenatal care than those classified as having inadequate health literacy (65.38 (53.85–76.92 vs. 46.15 (30.77–69.23), p = 0.014) (data not shown in the table).
shows the multiple linear regression results for the SAHLPA-18 score. In the final model, age group, self-perceived school performance, and income sufficiency remained significantly associated with SAHLPA-18 score. Adolescent participants scored, on average, 3.5 points lower on the SAHLPA-18 than adults, even after adjustment for covariates. Perceiving school-performance better than average was associated with higher health literacy, with a SAHLPA-18 score almost 3 points higher than for those who perceived their school performance average/low. Moreover, the SAHLPA-18 scores of pregnant women who reported suitable income were almost 3 points higher as compared with those reporting insufficient income.
This study investigated health literacy and its associated factors in pregnant adolescents and adults living in a rural low-income area in Northeastern Brazil. The results revealed low levels of health literacy among this population, with adolescent participants presenting worse results than adults. Almost all of the adolescent respondents (95.1%) had low health literacy. Lower health literacy was also associated with worse self-perception of school performance as compared with peers, receiving Bolsa Família, having lower social support from parents, and having had a lower record of recommendations for an adequate prenatal care in the pregnant cards in the bivariate analysis. In the multiple linear regression model, age group, self-perception school performance, and income sufficiency remained associated with health literacy.
When comparing our results with previous studies [31
] that evaluated health literacy in adolescents and adults, we observed that our sample presented a higher prevalence of inadequate health literacy. We found that 73.3% of our sample had inadequate health literacy, including 95.1% of adolescents and 53.3% of adults. Studies performed with pregnant adults [36
] reported inadequate health literacy ranging from 14% to 61% using different instruments, such as the Rapid Estimate of Adult Literacy in Medicine (REALM) [40
] and the Test of Functional Health Literacy in Adults (TOFHLA) [41
]. The REALM evaluates the ability to pronounce some medical words. This is different from the SAHLPA-18 used in the present study, which evaluates both, pronunciation and comprehension of medical terms. The TOFHLA incorporates a different concept to evaluate health literacy, i.e., assessing the person’s ability to read and comprehend some medical instructions such as those for treatment and exams. As far as we know, there are no studies evaluating health literacy among pregnant women with SAHLPA-18. Although there are validated versions of the TOFHLA [42
] and SAHLPA for the Brazilian population, it has been reported that the TOFHLA may be intimidating to people with lower education and it may have limited application for some vulnerable populations in developing countries [30
], such as those evaluated in the present study. Thus, it is possible that even higher percentages of low health literacy would have been found if we have evaluated the participants of the present study with the Brazilian version of the TOFHLA.
Regarding health literacy among adolescents, previous studies [23
] found rates of low health literacy varying from 23% to 48% in males and females. Although the high prevalence of inadequate health literacy in our sample may reflect poorer results for rural low-income participants, they may also reflect differences in relation to the health literacy tests used by the previous studies, which, in some cases, may use simpler questions and commands. For instance, when using the REALM-TEEN [43
], a previous study with 293 adolescents (14–19 years) from the United States, the authors reported a prevalence of health literacy of 24.2%. This instrument is a version of the REALM adapted to teenagers and evaluates only the ability to pronounce words. However, other studies with more complex health literacy tests, such as the Newest Vital Sign [23
], which tests literacy skills for numbers and words, and C-sTOFHLAd [44
], which assesses reading comprehension in two reading passages related to medical instructions, also found lower levels of health literacy in adolescents than seen in this study.
Our adolescent group had lower health literacy than the adults in the sample. Other studies have also found an association between age and health literacy. A previous study of adolescents aged 15 to 19 years found that poorer health literacy was associated with younger ages [45
], as did another study with adolescents aged 11 to 18 years [46
]. This may reflect the lower access to health information at younger ages, as well as developmental immaturity and less experience/interaction with the health system.
Poorer results among the younger participants could reflect the association between lower education level and health literacy. Education and health literacy are different concepts; therefore, the isolated analysis of education level does not necessarily explain health literacy [47
]. Health literacy develops from the intersection of several essential components related to the broad concept of literacy such as cultural and conceptual knowledge, listening, speaking, reading, writing and numeracy skills [48
]. Therefore, greater access to education could expose people to more health information. We did not include years of schooling in this analysis because of the collinearity with the participants’ age. This is also concerning as these are pregnant adolescents and having a baby may impact their academic trajectories.
It is well stablished that adolescent mothers already face greater risks related to pregnancy and childbirth, as well as their children. The incidence of adverse health conditions such as eclampsia and systemic infections are higher among adolescent mothers as compared with adults [49
]. Preterm birth, stillbirths, and newborn deaths are more frequent among adolescents as well [50
]. As lower health literacy is associated with less healthy choices, riskier health behavior and more inappropriate use of health services [52
], therefore, low health literacy may increase the risks associated with adolescent fertility for the mother and the child. Improving health literacy in the young pregnant population is an important intervention that might improve their health outcomes as well as that of their child. Health literacy is a factor that can be intervened in policy and practice before, during, and after adolescent pregnancy for potential positive health impacts immediately and over time. The low health literacy of this population must also be recognized, and health care systems must use this information to consider health interventions for improving health literacy, and also to ensure that health materials and health systems are easy-to-use and understandable for individuals across all health literacy skills. Health professionals, services, organizations, and systems must make health information and resources available and accessible to people, according to their health literacy strengths and limitations.
Regarding the perception of school performance, the present study revealed poorer health literacy among those reporting average/low school performance as compared with peers. As pointed out in previous studies [53
], negative perceptions can compromise students’ self-esteem, behavior, and motivation for learning. With this, the negative self-perception of school performance may also have discouraged the search for health information, and thus led to poorer health literacy.
The analyses indicate that a lower SAHLPA-18 score is associated with a lower income sufficiency and receiving Bolsa Família, which agrees with existing literature [31
]. The association between health literacy and income sufficiency remained after multivariate linear regression analysis. This association is explained by people with lower income having less opportunity to access health information and services or less support for health-related decision making, which consequently reduces the chances of developing health literacy. Socioeconomic inequality requires targeted interventions that address the specificities of people with inadequate health literacy.
In the bivariate results, health literacy was lower in pregnant women who also had a poor record of compliance with prenatal recommendations, i.e., worse adequacy of prenatal care. Women with limited health literacy may have less knowledge about some screening tests in the first and second trimesters of pregnancy [57
]. Another study indicated that pregnant women with low health literacy started prenatal care later than pregnant women with adequate health literacy [58
]. Thus, it is possible that pregnant women with lower health literacy were less concerned about carrying out all the tests and procedures recommended for an adequate prenatal care. The lack of association, in the multivariate analysis, may indicate the collinearity between adequacy of prenatal care and the age group. As presented in Table 1
, the adequacy of prenatal care was significantly worse for adolescents than for adults.
As for social support, pregnant women with inadequate health literacy had significantly lower social support from parents, although the association lost significance in the adjusted model. Other studies with non-pregnant populations have found a direct relationship between health literacy and social support [59
]. Lack of support from family may hinder the process of acquiring health-related information.
This study presents some limitations. Because the SAHLPA-18 instrument was developed to measure health literacy among adults, the poorer results found for adolescents may be overestimated. However, the SAHLPA is composed of simple medical terms normally used in routine health care consultations and procedures, and the inability of pregnant adolescents to understand these terms reflects an important health concern. This instrument does not evaluate other critical components and skills of health literacy, such as numeracy, language skills, and research skills, and we believe that looking at other aspects of health literacy in this population is an important topic for the future. Finally, the small sample size is another limitation of this study, which limited the power of our analyses and also limits the generalization or the results.