Predicting the Health‐Promoting Lifestyle Profile of Pregnant Women Based on Their Health Literacy Levels: A Cross‐Sectional Study
Background Pregnancy is a crucial period in a woman's life that significantly influences the health of both the mother and her child (Sahin et al. ). This unique phase precipitates physiological, psychological, and social changes in women. It is imperative for pregnant women to make decisions that align with the physiological transformations of pregnancy to yield favourable outcomes (Atkinson and Teychenne ). Their functions, decisions and health‐related behaviours have undeniable effects on health. Furthermore, these behaviours can impact fetal growth and development, leading to lifelong consequences for both women and their infants (Rezaee et al. ; Nguyen et al. ). In 2015, the United Nations adopted 17 items as Sustainable Development Goals (SDGs) to be achieved by all participating countries by 2030. The third goal of this programme is to ensure healthy lives and promote well‐being for people of all ages. According to a 2023 report from the United Nations, the global maternal mortality ratio decreased slightly from 227 maternal deaths per 100,000 live births in 2015 to 223 in 2020. However, this figure remains more than three times higher than the goal of 70 maternal deaths per 100,000 live births by 2030. Consequently, nearly 800 women continue to die every day from preventable causes related to pregnancy and childbirth. The majority of these deaths, around 95%, occur in low‐ and lower‐middle‐income countries (United Nations ). To achieve health promotion goals, health policymakers need to understand the factors influencing health. Adopting health‐promoting behaviours during pregnancy can reduce the risk of adverse pregnancy outcomes, such as obesity and diabetes, premature birth, the need for caesarean sections, maternal bleeding and infections, multiple hospitalisations, low birth weight, infant mortality, and ultimately maternal and infant mortality (Jalili Bahabadi et al. ). Health‐promoting behaviours can prevent many major health problems in later years, including hypertension, obesity, cardiovascular disease, diabetes and stroke (Ayaz‐Alkaya et al. ). The fact that a person chooses health‐promoting behaviours depends on several factors. Recently, health literacy has been considered as an important determining factor of health‐related behaviours (Kim and Oh ; Guler et al. ). The World Health Organisation defines health literacy as ‘cognitive and social skills determining individuals' motivation and ability to access, understand, and use the information to maintain and promote their health’ (Yusefi et al. ). In August 2020, this definition was revised with the release of the US government's Healthy People initiative, which described health literacy as ‘the degree to which individuals have the ability to find, understand, and use information and services to inform health‐related decisions and actions for themselves and others’ which stressed the importance of being able to utilise health information instead of merely grasping it (CDC ). The introduction of Healthy People 2030 signifies the first instance in the Healthy People initiative where health literacy is included in its framework. Achieving health literacy is acknowledged in both the foundational principles and overarching goals of Healthy People 2030 as essential for promoting health and well‐being (Santana et al. ). Actually, health literacy is important because it can affect people's ability to make informed health decisions, access necessary medical cares (such as preventive care), use medications properly, manage their diseases and maintain a healthy lifestyle (MedlinePlus ). Health literacy is a critical issue for various target groups. One of the vulnerable social groups is pregnant women. A systematic review in 2021 reported low health literacy in pregnant woman, although most studies were conducted in Western countries (Nawabi et al. ). Health literacy is a key factor that empowers women to participate in self‐care and child‐care activities (Masoumy, Hamedi‐Shahraki, and Zeraatpishe ; Shiri‐Mohammadabad and Afshani ). Low health literacy leads to inadequate health knowledge, failure to engage in health protection activities and limited access to health services, also resulting in the restricted utilisation of these services and is correlated with higher rates of hospitalisation and mortality (Eyimaya et al. ; Galle et al. ). Additionally, limited health literacy may elevate the risk of complications during pregnancy and childbirth, such as gestational diabetes, maternal depression and stress, stillbirth, congenital defects and low birth weight, which can have repercussions for both the mother and her child (Meldgaard, Gamborg, and Terkildsen ). On the other hand, pregnancy is seen as a prime opportunity for change, as women often feel a strong motivation to improve their health status which leads to better pregnancy outcomes. This period is referred to as ‘a teachable moment’ where efforts to boost health literacy can be effectively implemented through regular interactions with the healthcare system (Zibellini et al. ). Healthcare providers play a key role in the health of mothers and their child, and to provide better services, it is necessary to be aware of mothers' health literacy levels (Vlassak et al. ). Therefore, healthcare providers such as midwives and nurses should routinely assess maternal health literacy to identify opportunities for health promotion (Guler et al. ). Despite its importance, there is currently no programme in Iran to routinely assess the health literacy of mothers during pre‐pregnancy or prenatal care. As a result, the necessary interventions that require more attention cannot be accurately determined. Finally, based on our search and knowledge, the health‐promoting behaviours and level of health literacy have been investigated in various groups such as female students, inpatient women and university employees. These variables have not been studied together in pregnant women in Iran. Therefore, this study was conducted with the following objectives: Assessing the health literacy levels of pregnant women. Evaluating health‐promoting behaviours in pregnant women. Determining the relationship between health literacy and health‐promoting behaviours (and their subscales) in pregnant women. 

Methods 2.1 Design This cross‐sectional study was conducted between August 2022 and December 2022 to determine how health literacy and socio‐demographics variables can predict health‐promoting lifestyle among pregnant women. This study was conducted in two referral educational hospitals in Babol, the second most populous city in northern Iran. Babol is one of the most significant cities in northern Iran, known for its contributions to medicine, academia, politics, communication, culture and business. The hospitals selected for sampling were referral centres that served all segments of society in terms of socio‐economic status, making them a representative sample of the Iranian female population. 2.2 Sample This survey involves 308 pregnant women attending prenatal care clinics in training hospitals affiliated with Babol University of Medical Sciences (in Mazandaran, Iran). Participants were recruited using convenient sampling based on the inclusion criteria. Inclusion criteria were being pregnant and willingness to participate in the study, while the exclusion criteria included the presence of mental disability or severe illness in pregnant women. The sample size was determined according to the study's objectives, relying on previous research (Rashan et al. ) and considering the sample size from a similar study examining the relationship of factors influencing women's health‐promoting behaviours. To achieve the largest sample size, a minimum correlation coefficient ( r = 0.20) was used, with a 95% confidence interval and power level. This calculation was performed using GPOWER software 3, assuming a two‐tailed hypothesis, resulting in a sample size of approximately 300 pregnant women. In this study, questionnaires were completed for all 308 participants. 2.3 Measures To assess the participants' health‐promoting lifestyle status, the 52‐item health‐promoting lifestyle questionnaire (HPLP II) was utilised. The questionnaire encompasses six domains: interpersonal relations, nutrition, health responsibility, physical activity, spiritual growth and stress management. This questionnaire employs a 4‐point Likert scale (never = 1, sometimes = 2, often = 3, always = 4) (Dalyan and Kaya ). The total score of the HPLP II ranges from 52 to 208 and is determined by the mean score of the responses to all 52 HPLP items. The total HPLP II score categorise into four levels: the range 52–90 (poor), the range 91–129 (moderate), the range 130–168 (good) and the range 169–208 (excellent). High scores in each subscale indicate more frequent engagement in health‐promoting behaviours. The original version of the HPLP II was designed by Walker, Sechrist, and Pender  in English, which reported a Cronbach's alpha of 0.94 for the overall scale, and for the six subscales, it ranged from 0.79 to 0.87. The validity and reliability of this questionnaire were assessed in Iran, yielding a Cronbach's alpha of 0.81 for nutrition, 0.79 for physical activity, 0.91 for stress management, 0.75 for interpersonal relations, 0.86 for health responsibility, 0.64 for spiritual growth and 0.82 for the overall questionnaire (Mohammadi Zeidi, Pakpour Hajiagha, and Mohammadi Zeidi ). We employed the Health Literacy for Iranian Adults (HELIA) questionnaire developed by Montazeri et al. to assess health literacy in pregnant women. The HELIA measures five dimensions: ‘access’ (items 1–6), ‘reading’ (items 7–10), ‘understanding’ (items 11–17), ‘appraisal’ (18–21) and ‘decision‐making/behavioural intention’ (items 22–33). HELIA scores are categorised into four groups: inadequate and problematic (combined as ‘limited health literacy’), sufficient and excellent (grouped as ‘desired health literacy’). Scores on the HELIA range from 0 to 100, representing the following criteria: 0–50: inadequate, 50.1–66: problematic, 66.1–84: sufficient and 84.1–100 excellent (Montazeri et al. ). In Iran, Tavousi et al.  found that the Health Literacy Instrument for Adults (HELIA) is a valid and reliable tool for assessing health literacy in adults. The Cronbach's alpha coefficient for each subscale and the overall questionnaire ranged from 0.72 to 0.89. The socio‐demographic and fertility variables, aligned with the purpose of this study, were determined through a review of the literature. These variables include age, years of education, employment status, economic status, gravidity, parity, planning status of pregnancy, abortion history, gestational age, attendance in childbirth preparation classes and the source of health information. 2.4 Procedure The researcher, a master's student in Midwifery Counselling, visited prenatal care clinics to select pregnant women according to the eligibility criteria. The hard copy questionnaires were administered through face‐to‐face interviews, and sampling continued until 308 participants were reached. Verbal consent was obtained from each participant. Completing the socio‐demographic and fertility variables took about 5 min, the HPLP survey took 10–15 min and the health literacy assessment took approximately 5–10 min. Necessary permissions were obtained from clinic management prior to data collection. Additionally, before the questionnaires were filled out, the researcher provided the pregnant women with necessary information about the study's objectives. The women participated voluntarily and were assured their data would remain anonymous. 2.5 Data Analysis For statistical analysis, after collecting and ensuring the accuracy of the data entry, descriptive information about the participants was reported using measures of central tendency (mean) and the dispersion index (standard deviation), or in the form of numbers and percentages. To assess the normality of the data, the Kolmogorov–Smirnov test was employed. The Chi‐square test was used to examine the statistically significant relationship between qualitative variables, with Fisher's exact test applied in case of limitations in expected frequencies. The Pearson correlation coefficient test was utilised to evaluate the relationship between quantitative variables. Ultimately, linear regression was employed to predict the levels of health promotion behaviours using the independent variable of health literacy in the study. Considering that demographic characteristics and other factors might influence this relationship, these variables were taken into account for adjustment in the final analysis. The analysis presented regression coefficients and their 95% confidence intervals. The data were analysed using the IBM SPSS 23.0 statistical package program, and values of p < 0.05 were considered statistically significant. 

Design This cross‐sectional study was conducted between August 2022 and December 2022 to determine how health literacy and socio‐demographics variables can predict health‐promoting lifestyle among pregnant women. This study was conducted in two referral educational hospitals in Babol, the second most populous city in northern Iran. Babol is one of the most significant cities in northern Iran, known for its contributions to medicine, academia, politics, communication, culture and business. The hospitals selected for sampling were referral centres that served all segments of society in terms of socio‐economic status, making them a representative sample of the Iranian female population. 

Sample This survey involves 308 pregnant women attending prenatal care clinics in training hospitals affiliated with Babol University of Medical Sciences (in Mazandaran, Iran). Participants were recruited using convenient sampling based on the inclusion criteria. Inclusion criteria were being pregnant and willingness to participate in the study, while the exclusion criteria included the presence of mental disability or severe illness in pregnant women. The sample size was determined according to the study's objectives, relying on previous research (Rashan et al. ) and considering the sample size from a similar study examining the relationship of factors influencing women's health‐promoting behaviours. To achieve the largest sample size, a minimum correlation coefficient ( r = 0.20) was used, with a 95% confidence interval and power level. This calculation was performed using GPOWER software 3, assuming a two‐tailed hypothesis, resulting in a sample size of approximately 300 pregnant women. In this study, questionnaires were completed for all 308 participants. 

Measures To assess the participants' health‐promoting lifestyle status, the 52‐item health‐promoting lifestyle questionnaire (HPLP II) was utilised. The questionnaire encompasses six domains: interpersonal relations, nutrition, health responsibility, physical activity, spiritual growth and stress management. This questionnaire employs a 4‐point Likert scale (never = 1, sometimes = 2, often = 3, always = 4) (Dalyan and Kaya ). The total score of the HPLP II ranges from 52 to 208 and is determined by the mean score of the responses to all 52 HPLP items. The total HPLP II score categorise into four levels: the range 52–90 (poor), the range 91–129 (moderate), the range 130–168 (good) and the range 169–208 (excellent). High scores in each subscale indicate more frequent engagement in health‐promoting behaviours. The original version of the HPLP II was designed by Walker, Sechrist, and Pender  in English, which reported a Cronbach's alpha of 0.94 for the overall scale, and for the six subscales, it ranged from 0.79 to 0.87. The validity and reliability of this questionnaire were assessed in Iran, yielding a Cronbach's alpha of 0.81 for nutrition, 0.79 for physical activity, 0.91 for stress management, 0.75 for interpersonal relations, 0.86 for health responsibility, 0.64 for spiritual growth and 0.82 for the overall questionnaire (Mohammadi Zeidi, Pakpour Hajiagha, and Mohammadi Zeidi ). We employed the Health Literacy for Iranian Adults (HELIA) questionnaire developed by Montazeri et al. to assess health literacy in pregnant women. The HELIA measures five dimensions: ‘access’ (items 1–6), ‘reading’ (items 7–10), ‘understanding’ (items 11–17), ‘appraisal’ (18–21) and ‘decision‐making/behavioural intention’ (items 22–33). HELIA scores are categorised into four groups: inadequate and problematic (combined as ‘limited health literacy’), sufficient and excellent (grouped as ‘desired health literacy’). Scores on the HELIA range from 0 to 100, representing the following criteria: 0–50: inadequate, 50.1–66: problematic, 66.1–84: sufficient and 84.1–100 excellent (Montazeri et al. ). In Iran, Tavousi et al.  found that the Health Literacy Instrument for Adults (HELIA) is a valid and reliable tool for assessing health literacy in adults. The Cronbach's alpha coefficient for each subscale and the overall questionnaire ranged from 0.72 to 0.89. The socio‐demographic and fertility variables, aligned with the purpose of this study, were determined through a review of the literature. These variables include age, years of education, employment status, economic status, gravidity, parity, planning status of pregnancy, abortion history, gestational age, attendance in childbirth preparation classes and the source of health information. 

Procedure The researcher, a master's student in Midwifery Counselling, visited prenatal care clinics to select pregnant women according to the eligibility criteria. The hard copy questionnaires were administered through face‐to‐face interviews, and sampling continued until 308 participants were reached. Verbal consent was obtained from each participant. Completing the socio‐demographic and fertility variables took about 5 min, the HPLP survey took 10–15 min and the health literacy assessment took approximately 5–10 min. Necessary permissions were obtained from clinic management prior to data collection. Additionally, before the questionnaires were filled out, the researcher provided the pregnant women with necessary information about the study's objectives. The women participated voluntarily and were assured their data would remain anonymous. 

Data Analysis For statistical analysis, after collecting and ensuring the accuracy of the data entry, descriptive information about the participants was reported using measures of central tendency (mean) and the dispersion index (standard deviation), or in the form of numbers and percentages. To assess the normality of the data, the Kolmogorov–Smirnov test was employed. The Chi‐square test was used to examine the statistically significant relationship between qualitative variables, with Fisher's exact test applied in case of limitations in expected frequencies. The Pearson correlation coefficient test was utilised to evaluate the relationship between quantitative variables. Ultimately, linear regression was employed to predict the levels of health promotion behaviours using the independent variable of health literacy in the study. Considering that demographic characteristics and other factors might influence this relationship, these variables were taken into account for adjustment in the final analysis. The analysis presented regression coefficients and their 95% confidence intervals. The data were analysed using the IBM SPSS 23.0 statistical package program, and values of p < 0.05 were considered statistically significant. 

Results 3.1 Participants and Association Between Health Literacy and Participants' Characteristics In total, 308 participants in the age range of 17–45 years, with an average age of 27.98 ± 6.03 years, were studied. The frequency of education equal to 6 years or less in the studied women was very low (2.3%), and the majority of them (55.2%) had 7–12 years of education. About 90% of women were housewives. The number of women with a normal body mass index was 129 (41.9%), and the majority of them were in the second trimester of pregnancy (43.2%). About half of the pregnant women had no history of previous childbirth, although 22.1% reported a history of abortion. Considering that this study was conducted during the Covid‐19 period, a small percentage (15.9%) had participated in physiological childbirth classes. A significant percentage of them received information about their health and disease on the Internet (41.2%). The distribution of pregnant women according to health literacy in defined categories based on socio‐demographic and fertility characteristics is shown in Table . Data analysis using Chi‐square test in relation to the frequency of health literacy in terms of socio‐demographic and fertility variables showed that a significant difference was found among health literacy and only three variables—the women's education level, gravidity and history of abortion ( p < 0.05). 3.2 Health Literacy and Health‐Promoting Behaviours The mean and standard deviation of the health literacy and HPLP II scores in the pregnant women are provided in Table . The mean scores of the women's health‐promoting behaviours and health literacy were 70.31 ± 13.56 and 135.56 ± 17.38, respectively. The lowest score in the health literacy questionnaire was associated with the appraisal subscale (66.07 ± 17.81), and in the health‐promoting lifestyle questionnaire was related to the physical activity dimension (13.87 ± 3.87). Total scores of health literacy and health‐promoting behaviours are illustrated in Figure with their categories. Referring to Table , a significant and positive correlation was observed between health literacy and health‐promoting behaviours ( r = 0.53, p < 0.001). Furthermore, among the health literacy dimensions, decision‐making had the strongest correlation with health‐promoting lifestyle ( r = 0.55, p < 0.001). Additionally, all subscales of health literacy were related to all subscales of health‐promoting behaviours, and all of these relationships were statistically significant. 3.3 Variables Predicted to Affect Health‐Promoting Lifestyle Profile Table displays variables correlated with the health‐promoting lifestyle in the univariate linear regression, including health literacy, education, employment and attendance at childbirth preparation classes. These variables were input into the multiple linear regression model. Among the variables included in the model; health literacy (coefficient = 0.71, 95% CI: 0.58–0.83; p < 0.001), BMI (coefficient = 0.41, 95% CI: 0.07–0.75; p = 0.017) and attending childbirth preparation classes (coefficient = 9.06, 95% CI: 4.35–13.77; p < 0.001) were positively correlated with health‐promoting lifestyle. Regarding the relationship between health‐promoting behaviours and health literacy, the results indicated that health literacy was an independent and strong predictive variable related to HPLP in both univariate and multivariate analyses. In the univariate analysis, for each one‐unit increase in the health literacy score, on average, 0.69 of a unit was added to the HPLP score, which was statistically significant. In the multivariate analysis, with all study variables present in the model, a relationship persisted between these two variables. For each one‐unit increase in the health literacy score, about 0.7 of a unit was still added to the HPLP score ( p < 0.001). Regarding the relationship between dimensions of health literacy and the women's health‐promoting lifestyle, Table revealed that all dimensions of health literacy, in both univariate and multivariate analyses with all important variables in the model, were still related to the participants' health‐promoting behaviours. All of these relationships were statistically significant ( p < 0.001). 

Participants and Association Between Health Literacy and Participants' Characteristics In total, 308 participants in the age range of 17–45 years, with an average age of 27.98 ± 6.03 years, were studied. The frequency of education equal to 6 years or less in the studied women was very low (2.3%), and the majority of them (55.2%) had 7–12 years of education. About 90% of women were housewives. The number of women with a normal body mass index was 129 (41.9%), and the majority of them were in the second trimester of pregnancy (43.2%). About half of the pregnant women had no history of previous childbirth, although 22.1% reported a history of abortion. Considering that this study was conducted during the Covid‐19 period, a small percentage (15.9%) had participated in physiological childbirth classes. A significant percentage of them received information about their health and disease on the Internet (41.2%). The distribution of pregnant women according to health literacy in defined categories based on socio‐demographic and fertility characteristics is shown in Table . Data analysis using Chi‐square test in relation to the frequency of health literacy in terms of socio‐demographic and fertility variables showed that a significant difference was found among health literacy and only three variables—the women's education level, gravidity and history of abortion ( p < 0.05). 

Health Literacy and Health‐Promoting Behaviours The mean and standard deviation of the health literacy and HPLP II scores in the pregnant women are provided in Table . The mean scores of the women's health‐promoting behaviours and health literacy were 70.31 ± 13.56 and 135.56 ± 17.38, respectively. The lowest score in the health literacy questionnaire was associated with the appraisal subscale (66.07 ± 17.81), and in the health‐promoting lifestyle questionnaire was related to the physical activity dimension (13.87 ± 3.87). Total scores of health literacy and health‐promoting behaviours are illustrated in Figure with their categories. Referring to Table , a significant and positive correlation was observed between health literacy and health‐promoting behaviours ( r = 0.53, p < 0.001). Furthermore, among the health literacy dimensions, decision‐making had the strongest correlation with health‐promoting lifestyle ( r = 0.55, p < 0.001). Additionally, all subscales of health literacy were related to all subscales of health‐promoting behaviours, and all of these relationships were statistically significant. 

Variables Predicted to Affect Health‐Promoting Lifestyle Profile Table displays variables correlated with the health‐promoting lifestyle in the univariate linear regression, including health literacy, education, employment and attendance at childbirth preparation classes. These variables were input into the multiple linear regression model. Among the variables included in the model; health literacy (coefficient = 0.71, 95% CI: 0.58–0.83; p < 0.001), BMI (coefficient = 0.41, 95% CI: 0.07–0.75; p = 0.017) and attending childbirth preparation classes (coefficient = 9.06, 95% CI: 4.35–13.77; p < 0.001) were positively correlated with health‐promoting lifestyle. Regarding the relationship between health‐promoting behaviours and health literacy, the results indicated that health literacy was an independent and strong predictive variable related to HPLP in both univariate and multivariate analyses. In the univariate analysis, for each one‐unit increase in the health literacy score, on average, 0.69 of a unit was added to the HPLP score, which was statistically significant. In the multivariate analysis, with all study variables present in the model, a relationship persisted between these two variables. For each one‐unit increase in the health literacy score, about 0.7 of a unit was still added to the HPLP score ( p < 0.001). Regarding the relationship between dimensions of health literacy and the women's health‐promoting lifestyle, Table revealed that all dimensions of health literacy, in both univariate and multivariate analyses with all important variables in the model, were still related to the participants' health‐promoting behaviours. All of these relationships were statistically significant ( p < 0.001). 

Discussion In relation to the main purpose of this study, the analysis showed a positive correlation between health literacy scores and its domains with health‐promoting behaviours and their subscales. These results are consistent with those of other similar studies (Korkmaz Aslan et al. ; Bae and Yoon ; Yusefi et al. ). Therefore, the hypothesis of the study is confirmed. It seems that improving health literacy in pregnant women can lead them to choose healthier behaviours, ultimately improving the health status of this group, which also affects the health of the family. Consequently, it can be understood that individuals with better decision‐making abilities are likely to make better choices, resulting in improved health‐promoting behaviours. In essence, enhancing women's health literacy can positively impact various aspects of their health, including both physical and mental well‐being. Also, this study aimed to determine the health‐promoting behaviours and health literacy levels of pregnant women, revealing that 45.5% of participants had sufficient health literacy. A study by Taheri and colleagues in Tehran (the capital of Iran) revealed that 50% of pregnant women had sufficient health literacy (Taheri et al. ). In another study, the rate of sufficient health literacy was 33.9% (Guler et al. ). Some other studies reported limited health literacy rates of 79.8% in Egypt (Essam, Khafagy, and Alemam ), 66.1% in Turkey (Guler et al. ), and 55.3% in Southeast Asia (Rajah, Hassali, and Murugiah ). It is recognised that health literacy interacts with cultural characteristics and the health system of the region in which people reside. Consequently, these variations in results may be attributed to differences in study locations, the instruments utilised, various gestational ages, diverse health institutions collecting the data and other individual characteristics. This study also revealed a relationship between health literacy and education years, indicating that educated women had higher HELIA scores. In contrast to our findings, a study reported that the educational level of pregnant women had no effect on their health literacy level (Sahin et al. ). However, some other studies reported a significant correlation between women's education and their level of health literacy, aligning with our results (Elbarazi et al. ; Veerasetty et al. ; Tugut, Yesildag Celik, and Yılmaz ). This underscores the importance of implementing measures to enhance the health literacy of women with lower levels of education, enabling them to engage in correct health behaviours. The results revealed a significant relationship between a history of abortion and the health literacy score in pregnant women. Women who had a history of abortion had lower HELIA scores similar to Baharvand, Anbari, and Abdolian's findings . This finding contrasts with another study that found no statistically significant relationship between health literacy and a history of abortion (Sahin et al. ). Based on this finding, it is possible that improving women's health literacy has a preventive role on self‐induced abortions. No significant difference was found between women with different health literacy levels in terms of age category, employment status, BMI, gestational age, planning status of pregnancy, parity, attending childbirth preparation classes and the most common source of health and disease information. Consistent with our results, Ghotbizadeh et al.  found that there was no relationship between age and health literacy in pregnant women. Another study reported that among variables of age, education, occupation, Housing status and type of insurance, only the education variable was identified as a predictor of HL, accounting for 18% of the total variance in health literacy (Salarvand et al. ). In contrast, the study of Jiregna et al.  reported a significant relationship between age and health literacy. We suspect that this difference in results may be attributed to the age distribution of the target group in different studies. Among the domains of health literacy, the highest average score belonged to understanding (80.89 ± 14.60), while the lowest mean score belonged to appraisal (66.07 ± 17.81). These findings align with Moradzadeh et al.'s  study of mothers with children under 6 years old and Gaupšienė et al.'s  research on women giving birth in Vilnius Perinatology Center in Lithuania. Another study revealed that highest domain of health literacy was understanding, and the lowest domain was access (Tavananezhad et al. ). Izadirad, Ali Ahmadi, and Niknami  reported that among primigravid women, the highest health literacy scores were in ‘decision making’ and the lowest in ‘reading’. Iranian pregnant women may receive and understand their health information experientially, due to more contact with health care providers at comprehensive health centres, but they have less ability to evaluate, criticise and make decisions about health information. These variations in data could be due to differences in the studied populations, the methods of obtaining information, and the ability to appraise them. Therefore, it is important for healthcare providers to consider educational plans to empower women in evaluating health‐related information and recognising reliable sources. Our findings showed that the mean score of HPLP II in pregnant women was 135.56 ± 17.38, which falls within the good range. In domains of HPLP II, the scores from highest to lowest were interpersonal relations, spiritual growth, nutrition, health responsibility, stress management and physical activity. Some other studies reported that pregnant women have a moderate score of HPLP II and found that spiritual growth and physical activity had the highest and lowest mean scores (Pazandeh et al. ; Masjoudi et al. ; Fathnezhad‐Kazemi, Aslani, and Hajian ), which aligns closely with our results. The minimum and maximum scores may be influenced by pregnancy‐related beliefs of this population. For instance, the perception that physical activity should be limited during pregnancy can result in a lower score in this subscale, while the emphasis on relaxation and promoting well‐being during pregnancy can lead to a higher score in spiritual growth. The low score of physical activity in several studies shows the importance of emphasising physical activity and its benefits during pregnancy and lifelong by healthcare providers in prenatal care. Based on the results of the present study, health literacy is a strong predictive variable that is related to health‐promoting behaviours, similar to many other studies (Ranjbaran, Chollou, and Babazadeh ; Ydirin ; Bae and Yoon ). The results also demonstrated a significant impact of attending childbirth preparation classes on the health‐promoting behaviours of pregnant women. Thus, greater emphasis on educational programmes, such as childbirth preparation classes tailored to participants' needs, could help women adopt healthier behaviours. Eventually, this study showed that health‐promoting lifestyle and health literacy have a positive relationship in the presence of all studied variables. Therefore, Healthcare providers, especially midwives and nurses, should pay more attention to the fact that improving certain health‐related skills in women (such as reading, understanding, access to information, appraisal and decision‐making) can lead them to exhibit healthier behaviours, which can affect the future health of the mother and her child. 4.1 Study Limitations Due to the cross‐sectional nature of the present study, discovered correlations cannot accurately establish a cause‐and‐effect relationship, which was a limitation of the study. Furthermore, since this study specifically focused on a city in Iran, generalising the results to other cultural contexts and even the whole of Iran is challenging, and it's important to account for cultural nuances. 

Study Limitations Due to the cross‐sectional nature of the present study, discovered correlations cannot accurately establish a cause‐and‐effect relationship, which was a limitation of the study. Furthermore, since this study specifically focused on a city in Iran, generalising the results to other cultural contexts and even the whole of Iran is challenging, and it's important to account for cultural nuances. 

Implications for Public Health Nursing Currently, many clinical staff including midwives and nurses are trying to promote healthy lifestyle behaviours in pregnant women during counselling and training sessions. They are trying to investigate the factors affecting it and remove the barriers. But it seems that health literacy, which has a significant effect on healthy behaviours, has not been sufficiently considered. This study was conducted with the aim of drawing more attention to the status of health literacy of pregnant women and its correlation with health‐promoting behaviours. The findings from this study enable healthcare providers to gain deeper insights into the health literacy levels of pregnant women and to explore effective intervention strategies, ultimately enhancing the health of the mother, child, and family. Assessing health‐promoting behaviours and health literacy in pregnant women by health providers during prenatal care helps identify dimensions that may be receiving less attention during pregnancy and offer targeted solutions. We recommend that healthcare providers, policymakers and public health professionals integrate health literacy assessments into prenatal care practices. 

Conclusions Health literacy is an important factor in predicting health‐promoting behaviours. The domain of appraisal in health literacy and physical activity in health‐promoting behaviours among pregnant women had the lowest score. The results can guide healthcare interventions being tailored to the needs of pregnant women. Future studies are recommended to find the most cost‐effective interventional programmes to promote health literacy and health‐related behaviours in pregnant women. 

The Research Ethics Committee of Babol University of Medical Sciences approved this study on November 14, 2022, and assigned it the reference number (IR.MUBABOL.REC.1401.130). Necessary permissions were obtained from the clinics' management before data collection. Women participated voluntarily and were assured that data would remain anonymous. The study's purpose was explained to the women, and written informed consent was obtained from them before the interview. All methods were conducted in accordance with the relevant guidelines and ethical standards of the Declaration of Helsinki. 

The authors have nothing to report. 

The authors declare no conflicts of interest. 

