{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T06:17:51Z","timestamp":1787897871763,"version":"build-2784847793"},"reference-count":27,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T00:00:00Z","timestamp":1787875200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Public Health"],"abstract":"<jats:p>\n                    Health literacy is a modifiable determinant of maternal health and an important condition for equitable access to antenatal information, shared decision-making, and preventive care. Reliable and brief instruments are needed to monitor health literacy during pregnancy and to guide public health interventions. This study validated the Portuguese version of the 12-item European Health Literacy Survey questionnaire (HLS19-Q12) among pregnant women and examined its psychometric properties among pregnant women. A descriptive cross-sectional psychometric study was conducted with 886 pregnant women recruited through antenatal care services in Portugal. Factorial validity was assessed using exploratory factor analysis and confirmatory factor analysis with the diagonally weighted least squares (DWLS) estimator; reliability was evaluated using Cronbach\u2019s alpha and McDonald\u2019s omega; and construct validity was examined through correlations with digital and navigational health literacy indices. The results supported a unidimensional structure for the HLS19-Q12 [\u03c7\n                    <jats:sup>2<\/jats:sup>\n                    (50)\u202f=\u202f221.77,\n                    <jats:italic>p<\/jats:italic>\n                    \u202f&amp;lt;\u202f0.001; CFI\u202f=\u202f0.993; TLI\u202f=\u202f0.991; RMSEA\u202f=\u202f0.062, 90% CI (0.054, 0.071); SRMR\u202f=\u202f0.046]. Standardized factor loadings ranged from 0.59 to 0.80. Internal consistency was high (\n                    <jats:italic>\u03b1<\/jats:italic>\n                    \u202f=\u202f0.86;\n                    <jats:italic>\u03c9<\/jats:italic>\n                    \u202f=\u202f0.87), and moderate positive correlations with digital (r\u202f=\u202f0.65) and navigational (\n                    <jats:italic>r<\/jats:italic>\n                    \u202f=\u202f0.61) health literacy supported convergent validity. The Portuguese HLS\n                    <jats:sub>19<\/jats:sub>\n                    -Q12 is a valid and reliable instrument for assessing general health literacy among pregnant women. Following further validation and implementation research, the Portuguese HLS\n                    <jats:sub>19<\/jats:sub>\n                    -Q12 may have potential to support population monitoring of general health literacy among pregnant women and to inform targeted public health interventions.\n                  <\/jats:p>","DOI":"10.3389\/fpubh.2026.1920509","type":"journal-article","created":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T05:33:44Z","timestamp":1787895224000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Measuring health literacy for maternal health surveillance: psychometric validation of the Portuguese HLS19-Q12 among pregnant women"],"prefix":"10.3389","volume":"14","author":[{"given":"Nuno","family":"Ferreira","sequence":"first","affiliation":[{"name":"Nursing Research Innovation and Development Centre of Lisbon (CIDNUR), School of Nursing, Universidade de Lisboa","place":["Lisbon, Portugal"]},{"name":"Unidade Local de Sa\u00fade Viseu D\u00e3o-Laf\u00f5es","place":["Viseu, Portugal"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Manuela","family":"Ferreira","sequence":"additional","affiliation":[{"name":"Universidade Polit\u00e9cnica de Viseu, Escola Superior de Sa\u00fade, Viseu, Portugal; Univ Coimbra, UICISA:E","place":["Coimbra, Portugal"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andreia","family":"Costa","sequence":"additional","affiliation":[{"name":"Nursing Research Innovation and Development Centre of Lisbon (CIDNUR), School of Nursing, Universidade de Lisboa","place":["Lisbon, Portugal"]},{"name":"Instituto de Sa\u00fade Ambiental da Faculdade de Medicina da Universidade de Lisboa","place":["Lisboa, Portugal"]},{"name":"Laborat\u00f3rio para a Sustentabilidade do Uso da Terra e dos Servi\u00e7os dos Ecossistemas - TERRA","place":["Lisboa, Portugal"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,8,28]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"80","DOI":"10.1186\/1471-2458-12-80","article-title":"Health literacy and public health: a systematic review and integration of definitions and models","volume":"12","author":"S\u00f8rensen","year":"2012","journal-title":"BMC Public Health"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"14129","DOI":"10.3390\/ijerph192114129","article-title":"Measuring comprehensive, general health literacy in the general adult population: the development and validation of the HLS19-Q12 instrument in seventeen countries","volume":"19","author":"Pelikan","year":"2022","journal-title":"Int J Environ Res Public Health"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"3847","DOI":"10.3390\/ijerph18073847","article-title":"Health literacy in pregnant women: a systematic 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cross-sectional study in Nigeria","volume":"3","author":"Bello","year":"2022","journal-title":"Public Health Pract"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"180","DOI":"10.1016\/j.wombi.2020.01.010","article-title":"Effect of health literacy interventions on pregnancy outcomes: a systematic review","volume":"34","author":"Zibellini","year":"2021","journal-title":"Women Birth"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"2963","DOI":"10.1186\/s12889-025-24225-7","article-title":"Health literacy and its determinants among pregnant women in Portugal","volume":"25","author":"Ferreira","year":"2025","journal-title":"BMC Public Health"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"4225","DOI":"10.3390\/ijerph19074225","article-title":"Health literacy in Portugal: results of the health literacy population survey project 2019-2021","volume":"19","author":"Arriaga","year":"2022","journal-title":"Int J Environ Res Public Health"},{"key":"ref10","volume-title":"Stata Statistical Software: Release 18","year":"2023"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"2191","DOI":"10.1001\/jama.2013.281053","article-title":"World medical association declaration of Helsinki: ethical principles for medical research involving human subjects","volume":"310","year":"2013","journal-title":"JAMA"},{"key":"ref12","volume-title":"IBM SPSS Statistics for Mac, Version 30.0","year":"2026"},{"key":"ref13","volume-title":"Jamovi, version 2.7.34","year":"2026"},{"key":"ref14","volume-title":"R: A Language and Environment for Statistical Computing","year":"2025"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1080\/19312458.2020.1718629","article-title":"Use omega rather than Cronbach\u2019s alpha for estimating reliability","volume":"14","author":"Hayes","year":"2020","journal-title":"Commun Methods Meas"},{"key":"ref16","volume-title":"An\u00e1lise de equa\u00e7\u00f5es estruturais: 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Modeling","author":"Kline","year":"2005"},{"key":"ref22","volume-title":"Structural Equation Modeling With AMOS: Basic Concepts, Applications, and Programming","author":"Byrne","year":"2000"},{"key":"ref23","doi-asserted-by":"publisher","first-page":"238","DOI":"10.1037\/0033-2909.107.2.238","article-title":"Comparative fit indexes in structural models","volume":"107","author":"Bentler","year":"1990","journal-title":"Psychol Bull"},{"key":"ref24","doi-asserted-by":"publisher","first-page":"3079","DOI":"10.1186\/s12889-024-20504-x","article-title":"Psychometric validation of the French version of two scales measuring general (HLS19-Q12) and navigational (HLS19-NAV) health literacy using the Rasch model","volume":"24","author":"Touzani","year":"2024","journal-title":"BMC Public Health"},{"key":"ref25","doi-asserted-by":"publisher","first-page":"116","DOI":"10.1016\/j.puhe.2024.09.022","article-title":"Validation of the Spanish version of the health literacy survey (HLS19-Q12) in 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