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 Table of Contents  
Year : 2022  |  Volume : 9  |  Issue : 2  |  Page : 116-123

The relationship between health literacy and patterns of drug use in pregnancy

1 Department of Nursing, Faculty of Health Sciences, Bandırma Onyedi Eylul University, Bandırma/Balıkesir, Turkey
2 University of Health Sciences Turkey, Gulhane Faculty of Nursing, Ankara, Turkey
3 Department of Nursing, Health Sciences Faculty, Usak University, Uşak, Turkey

Date of Submission22-May-2021
Date of Decision12-Apr-2022
Date of Acceptance16-Apr-2022
Date of Web Publication10-Jun-2022

Correspondence Address:
Dr. Yilda Arzu Aba
Department of Nursing, Faculty of Health Sciences, Bandırma Onyedi Eylul University, Bandırma/Balıkesir
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jnms.jnms_79_21

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Context: Drug use during pregnancy is an important issue that is frequently encountered and difficult to decide on as it is closely related to the health of both the mother and the fetus.
Aim: This study was conducted to identify the relationship between the health literacy level and drug use in pregnant women.
Settings and Design: This was a descriptive cross-sectional study in a state hospital's outpatient department in Turkey in 2017.
Materials and Methods: In this study, 469 pregnant women were included with simple random sampling. The data collection form included sociodemographic characteristics and drug use behavior of pregnant women and the Health Literacy Scale (HLS).
Statistical Analysis: Descriptive statistics, t-test, Mann–Whitney U, Kruskal–Wallis, ANOVA, Bonferroni, and multiple regression analysis were used.
Results: The mean HLS subdimension scores were access 21.7 ± 3.4, understanding 28.1 ± 4.8, appraisal 34.2 ± 5.0, application 22.5 ± 2.9, and total score was 106.6 ± 14.01. We found that 49% of the variance related to the HLS score was associated with using the drugs recommended by the physician regularly (beta = −1.665, P < 0.05) and knowing the foods that should not be consumed with the drugs (beta = −4.024, P < 0.05).
Conclusions: The health literacy levels of pregnant women were found to be relatively adequate. The increase in the level of health literacy of pregnant women affects their drug use behavior positively. Therefore, planning for the improvement of pregnant women's health literacy is recommended.

Keywords: Drug, Health literacy, Pregnancy, Women

How to cite this article:
Aba YA, Basak T, Sevimli S. The relationship between health literacy and patterns of drug use in pregnancy. J Nurs Midwifery Sci 2022;9:116-23

How to cite this URL:
Aba YA, Basak T, Sevimli S. The relationship between health literacy and patterns of drug use in pregnancy. J Nurs Midwifery Sci [serial online] 2022 [cited 2022 Oct 7];9:116-23. Available from: https://www.jnmsjournal.org/text.asp?2022/9/2/116/347150

  Introduction Top

According to the UNESCO's definition (2014), literacy is the ability to identify, understand, interpret, combine, communicate, and calculate by using the various types of written sources and records.[1] According to the definition in the American Medical Institute's report, health literacy is “the level of the capacity to acquire, understand, and perceive health information and services necessary to make appropriate individual decisions about health.”[2] The criteria used to evaluate health literacy are being able to read the prescription written by the doctor, to know the date of the next follow-up, and to read written material such as forms. Individuals are expected to have access to information, make sense of it, use it, and protect and improve their health thanks to health literacy.[2] While the adult literacy rate has increased in the past decade, women make up 64% of nonliterate adults.[1] Studies have revealed various relationships between health literacy and the health-related behaviors and outcomes.[3] Adequate health literacy is a must for strengthening the possibility of changing the individual's behavior and lifestyle, providing access to health systems, and improving health.[4] The World Health Organization (WHO) has emphasized that health literacy should be seen as an integral part of protective and primary health-care services to the community.[5]

Drug use during pregnancy is an important issue that is frequently encountered and difficult to decide on as it is closely related to the health of both the mother and the fetus. The use of drugs is very important for women with certain chronic medical conditions such as epilepsy, diabetes, inflammatory bowel disease, and asthma. The benefits provided by the drug for the mother and the fetus may outweigh the teratogenic risk.[6] However, approximately 1% of all birth anomalies are caused by maternal drug use.[7] Pregnant women have also been shown to perceive the teratogenic risks of drug use unrealistically.[7]

According to the results of the Turkey Demographic and Health Survey (2013), 23.7% of pregnancies are unplanned and unwanted.[8] This indicates the possibility of women using prescribed or over-the-counter drugs for various reasons without realizing they are pregnant.[6],[9] Based on the results of two systematic reviews, drug use is common in pregnancy and this rate has been reported as between 27% and 93% in developing countries.[10],[11] Of the pregnant women, 32.6% were found to have used drugs in the month before pregnancy, 15.0% at the time they found out that they were pregnant, 50.1% during the period the survey was implemented, and 80.5% during the first trimester in a survey study conducted with 359 pregnant women in Turkey.[12] In addition, the percentage of the use of drugs in categories D and X in these four groups was 14%, 13.5%, 2.9%, and 5.9%, respectively.[12] Similarly, another study in Japan found the ratio of pregnant women using one or more drugs to be 78.4% before learning they were pregnant, 57.1% from the time they learned of the pregnancy until the 12th week, and 68.8% after the 12th week.[13] Other studies have shown that the rate of over-the-counter drug use is higher than that of prescribed ones.[12],[14]

One of the variables affecting drug use is health literacy.[15] Pregnant women with sufficient health literacy are thought to be able to pay more attention to the principles of drug use. Inadequacy in understanding the drug label/prescription information and drug administration mistakes is reported to be more common in individuals with a low health literacy level.[15] A multinational study found that negative beliefs about drugs were more common in pregnant women with low health literacy.[16] The same study recommended that clinicians consider the burden of low health literacy in certain health behaviors, such as medication use during pregnancy and nonadherence to treatment.[16] A systematic review showed that low health literacy in pregnant women is associated with negative beliefs about drugs and noncompliance with prescription drugs.[17] In a systematic review examining how pregnant women make decisions regarding drug use, it was shown that concerns about the baby's health and future pregnancy are important both during pregnancy and after delivery in the decision-making process.[18] Pregnant women's beliefs and fears about the safety of drugs have an impact on their adherence to medication.[19] Furthermore, an online survey showed that pregnant women regularly use the Internet to access drug information, and the reason for this is to ensure the safety of their babies.[19] The ability of the pregnant women to provide, understand, and use basic health-related information and to make appropriate health decisions for herself and the fetus is affected by the level of health literacy.[20] It is recommended to meet the information needs of pregnant women to increase health literacy in pregnant women.[21] Studies examining the relationship between health literacy and drug use pattern during pregnancy are limited in Turkey. Since social and cultural differences between populations may be affected the results, this study was conducted to identify the relationship between the health literacy level and drug use in pregnant women in Turkey.

  Materials and Methods Top

Study design and sample

This was a descriptive, cross-sectional study. The population of this study consisted of pregnant women who presented to Uşak Training and Research Hospital's outpatient department in Turkey. No sample calculation was made and 469 pregnant women who accepted to participate in the study between January 10, 2017, and June 30, 2017 were included with the simple random sampling. Because we did not initially calculate the sample size, at the end of the study, we calculated the power of our sample size. For the sample of 441 people, the Health Literacy Scale (HLS) had a 95% confidence interval, an effect size of 1.55, and a power of 0.89.

Pregnant women who were able to speak Turkish were literate and volunteered to participate in the study were included. Pregnant women with communication problems were excluded from the study.

The specific study questions were as follows:

  1. What is the health literacy level of pregnant women?
  2. Is there a relationship between health literacy and patterns of drug use in pregnancy?

Data collection

The data were obtained using the sociodemographic data form and HLS. The demographic information form created by the researchers included 30 questions on the sociodemographic characteristics and drug use behavior of pregnant women. The original of the “HLS” was developed by Tobi, Bruzari, and Sorenson and the Turkish validity (content validity) and reliability (test-retest, r = 0.74) study was conducted by Aras and Temel in 2015.[22],[23] The Cronbach's alpha value was found to be 0.92.[23] The scale containing 25 items consists of four subscales that include the access (5 minimum-25 maximum. score), understanding (7 minimum-35 maximum. score), appraisal (8 minimum-40 maximum score), and application (5 minimum-25 maximum score) participants. The minimum scale score is 25 points and the maximum 125 points; a higher score indicates a higher health literacy level of the individual. The scale items are answered by the participants in a Likert structure as “5: I have no difficulty, 4: I have little difficulty, 3: I have some difficulty, 2: I have a lot of difficulty, 1: I cannot do it/I have no talent/impossible.”[22],[23] The Cronbach's alpha value was found to be 0.92 in our study.

The data of the study were collected by the investigators using the face-to-face interview technique from the pregnant women at the pregnancy outpatient department at an appropriate time.

Ethical considerations

Written permission was obtained from the Uşak University Interventional Research Ethics Committee (09.01.2017/2017-02) and the Uşak Training and Research Hospital, where the study will be conducted. The study protocol was designed in compliance with the principles of the Declaration of Helsinki. In addition, the verbal and written informed consent of pregnant women included in the study was obtained after they were informed of the purpose and method of the research.

Statistical analysis

The data obtained were evaluated in a computer environment using the SPSS software version 15.0 (SPSS Inc., Chicago, IL) program. Mean values, standard deviations, numbers, and percentages were used in the identification of the data. The compliance of the data with a normal distribution was evaluated with the Kolmogorov–Smirnov test. The t-test, Mann–Whitney U-test, Kruskal–Wallis test (KW), ANOVA test, Bonferroni-corrected Mann–Whitney U-test, and multiple regression analysis were used in the analysis of the data. During the statistical analyses, the P value was accepted as significant if under 0.05.

  Results Top

Four hundred and sixty-nine pregnant women participated in this study. However, 28 pregnant women were excluded from the study due to the lack of data and the study was completed with 441 pregnant women.

Sociodemographic characteristics and mean health literacy scores are presented in [Table 1]. A statistically significant relationship was found between the HLS scores and the educational status, occupational status, the pregnancy being planned, and the number of previous pregnancies (P < 0.01) but not between the HLS scores and the age groups and gestational week (P > 0.05).
Table 1: Comparison of health literacy score based on the sociodemographic characteristics and health literacy states in pregnant women (n=441)

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[Table 2] shows using drugs for chronic disorders. The mean HLS score was 107.2 ± 14.9 in pregnant women who used their drugs regularly and 105.0 ± 12.9 in those who did not, with a statistically significant difference (Z = −2.19, P < 0.05).
Table 2: Prevalence of using drugs in pregnancy and mother's perception about it (n=441)

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The women's drug use behavior during pregnancy is shown in [Table 3]. The mean HLS was 108.2 ± 13.1 in those who checked the expiration date of the drugs, 99.7 ± 14.6 in those who sometimes checked it, and 97.1 ± 17.1 in those who never did so. The difference between these groups was statistically significant (KW = 26.92, P < 0.01). This difference was found to originate from women who checked and did not check the expiration date in the advanced statistical analysis performed.
Table 3: Drug using behaviors of pregnant Turkish women, (n=441)

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The mean HLS score was 108.1 ± 13.5 in pregnant women who always paid attention to the storage conditions of the drugs, 100.7 ± 12.4 in those who sometimes did so, and 99.6 ± 18.2 in those who did not pay attention to these conditions, with a statistically significant difference between the groups (KW = 26.20, P < 0.01). The mean HLS was 106.9 ± 14.0 in pregnant women who informed the physician regarding their drug/food allergy state and 100.7 ± 9.9 in those who did not, and the difference was found to be statistically significant (KW = 7.27, P < 0.05).

The mean HLS score was 109.7 ± 13.8 in the pregnant women who knew the foods that should not be consumed with their medication and 102.6 ± 13.2 in those who did not, again with a statistically significant difference (Z = −2.62, P < 0.01). Similarly, the mean HLS score was 108.4 ± 15.1 in the pregnant women who knew the herbal products that should not be consumed with their medication and 105.3 ± 12.6 in those who did not, with a statistically significant difference (F = 5.68, P < 0.01).

We found that 49% of the variance related to the HLS score in pregnant women was associated with using the drugs recommended by the physician regularly [Table 4].
Table 4: Multiple regression analysis of variables related to the Health Literacy Scale score of pregnant women (Variance: 49%)

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  Discussion Top

Although health literacy in the gestational period is a very important issue in terms of both maternal and fetal health, the literature on the subject is limited.[24] This study was conducted to identify the relationship between the health literacy level and drug use in pregnant women.

The health literacy levels of pregnant women were found to be relatively adequate in our study. The health literacy category was “inadequate” (24.5%) or “problematic” (40.1%) in 64.6% of Turkey's adult population in a health literacy study (2014) conducted on adults in Turkey.[25] In the study conducted in Turkey, it was determined that the health literacy levels of pregnant women were high.[26] In a systematic review study, it was noted that the levels of health literacy in pregnant women differed.[17] The reason for the high average health literacy levels of pregnant women in our study in contrast to the general population study could be the implementation of the continuing “Safe Motherhood” training and consultancy program launched in Turkey in 2004. This health-care education and counseling program offered to women during their pregnancy and the puerperium is thought to contribute to the increase of health literacy. Furthermore, the fact that too many tools have been developed for health literacy measurements limits the international comparability of the results.

In our study, it was found that the education level, occupational status, planned pregnancy, and the number of previous pregnancies affected the health literacy levels of pregnant women. Health literacy has been reported to be related to demographic and socioeconomic factors such as old age, education level, and poverty in the Institute of Medicine report.[27] The health literacy level of individuals with a high educational level was found to be higher in the Turkey Health Literacy study.[25] Health literacy was also found to be higher in young people without financial difficulties, those with higher education levels, and females in the European Union study.[28] In the literature, it is reported that individuals evaluate their health better as their education level increases.[29] In addition, there are different studies reporting that the level of health literacy increases as the education level increases in pregnant women.[21],[26],[30] In a study conducted in Iran, they reported that as the education and income levels of pregnant women increased, their health literacy levels also increased.[31] These results draw attention to the need to take measures to increase the level of health literacy so that pregnant women with low education and income levels can take the right decisions about their health.

The pregnancy was found to be unplanned in about 25% of the pregnant women in our study. It is reported that unplanned pregnancies may play a role in negative health behaviors such as smoking in pregnancy, inadequate vitamin usage, and smaller weight increase than recommended or no weight increase.[32],[33],[34]

Health literacy levels of the pregnant women who had experienced at least one pregnancy were found to be high in our study. Similarly, in a multicenter study, it was reported that the health literacy levels of pregnant women without living children were lower.[16] The high health literacy level of women with a previous pregnancy was evaluated as an expected result as the woman benefits from health-care services the most and also receives the services of the “Safe Motherhood” education and counseling program in Turkey during this period. Effective prenatal care has been reported to be an important and effective tool in ensuring maternal health literacy.[31],[34]

In this study, 92.1% were receiving vitamin/mineral support in pregnancy. Only 63.4% had used folic acid before the pregnancy and during the first trimester. Similarly, the rate of drug use for chronic diseases is 26% of all pregnancies in the literature.[41] The first study on drug use during pregnancy was conducted in 1990 and it was found that the rates of drug use containing vitamins and minerals varied between 82% and 100%.[9] Significant international differences have been found in the rates of general drug use in pregnancy.[11] Drug use in pregnancy except for vitamins and minerals in the Organization for Economic Co-operation and Development (OECD) countries has been shown to be lowest in Northern European countries and highest in France (93%) and Germany (85%).[11] The drug use rate in any period of pregnancy was found to be 88.8% in a US study.[35] Although differences between the study methods makes comparing the results of drug use studies difficultIn a study conducted in Italy, similar to our study, it was reported that the majority of women used folic acid/iron preparations.[36] In a study conducted in Saudi Arabia, it was stated that the most frequently used drugs by pregnant women were vitamins, paracetamol, herbal products and antiemetics.[37] In a study conducted in Pakistan, It has been reported that drug use is common during pregnancy, and among the most commonly prescribed drugs are iron preparations-vitamin and mineral supplements (79.4%), followed by analgesics (6.2%) and anti-bacterials (2.2%).[38] The rate of folic acid use before the pregnancy and in the first trimester was 63.4% in our study. The rate of folic acid use in the first trimester was found to be 65.2% in a study conducted in China.[39] The rate of folic acid use was 26.9% before pregnancy and 94.6% during pregnancy in a study conducted in Lebanon.[40] These differences in studies can be associated with differences in health care delivery. The data obtained both in our study and in other studies revealed that pregnant women need more detailed information about increasing their folic acid intake in the prenatal period and in the first trimester of pregnancy.

In a study on drug compliance among pregnant women using drugs for chronic diseases, it was found that most pregnant women had low drug compliance, and the main factor affecting drug compliance was women's beliefs about drug use.[41] When the perceptions of the pregnant women regarding the risks of drug use were evaluated in our study, some of pregnant women stated that drug use was always safe as long as it was under the physician's control and others felt they could be used if required during pregnancy. However, although the majority of pregnant women had positive thoughts regarding drug use in pregnancy, the rate of regular drug use was found to be 71.9%. Low health literacy in pregnancy to be associated with drug non-adherence in another study.[16] The health literacy level of the patients who were using their medication regularly was higher in our study. Similar to our study, in a limited number of studies, it was reported that 75% and 89.1% of pregnant women did not go beyond the dose and duration of use in drug use during pregnancy.[42],43]pregnant women with a chronic disease may use their regular medication unintentionally during the first months of pregnancy. This particular ratio was 17% in our study. Although other studies differ according to countries, these rates were found to be between 8.4% and 72.4%.[44],[45],[46] Effective communication methods should be used with pregnant women who feel anxiety regarding their drug use without being aware of their pregnancy. It has been reported that providing adequate counseling on teratogenic risks to pregnant women will improve their medication adherence during pregnancy.[47]

The most important factor affecting the success of medical treatment is the correct and regular use of drugs. The health literacy level was higher in pregnant women who checked the expiration date of drugs, paid attention to the storage conditions of drugs, and knew the foods and herbal products that should not be consumed together with their drugs in our study. A study determined the relationship of health literacy with drug use habits and correct drug use for the first time. A strong relationship was shown between an inadequate health literacy level and misuse of the measured dose inhaler asthma drugs.[48] In a study, it was reported that individuals with low health literacy do not use their medicines properly and cannot understand the messages about health well.[49]

The single-center nature of our study limits the generalization of the results. The presence of several scales developed for the evaluation of health literacy has limited comparison with the results of other studies.

  Conclusions Top

The results of this study are important as it is the first study on the subject from our country. The development of health literacy is an important issue for Turkey's health policies. The health literacy level of pregnant women with a high level of education, who are currently employed, have a planned pregnancy and have experience of at least one previous pregnancy was found to be higher in our study. Besides, pregnant women with a high health literacy level were found to show positive drug use behavior.

Conflicts of interest

There are no conflicts of interest.

Author contributions

All authors took part in the design of the study and were responsible for the supervision of data collection as well as the analysis of data.

Financial support and sponsorship


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  [Table 1], [Table 2], [Table 3], [Table 4]


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