Date of Award


Document Type


Degree Name

Doctor of Philosophy (PhD)



Research Advisor

Ann Cashion, PhD


Bobby Bellflower, DNSc Jay Bringman, M.D. Risa Ramsey, PhD Mona Wicks, PhD


Diabetes, Health Literacy, LAD, Pregnancy, REAL-G, REALM


Purpose/Objectives: Poor health literacy is a problem for over 45% of American adults and is associated with a variety of adverse health outcomes. Low health literacy has been associated with poor prenatal care utilization and a higher likelihood of poorer glycemic control. Poor glycemic control can lead to poor birth outcomes for both the mother and infant. Health literacy levels of pregnant women with diabetes can influence these outcomes and need to be known early in the pregnancy. Interventions can influence tighter glycemic control and lessen the impact of diabetes for the mother and infant. Therefore, the purpose of this study was to explore the associations among health literacy levels and health outcomes in pregnant women with pregestational and gestational diabetes.

Methods: With a sample of 32 pregnant women in an urban, safety-net clinic in the South we measured health literacy using the Rapid Estimate of Adult Literacy in Medicine (REALM), the Literacy Assessment for Diabetes (LAD), and the Rapid Estimate of Adult Literacy in Genetics (REAL-G) and determined glycemic control. In addition, we evaluated three questions from the Short Test of Functional Health Literacy in Adults (S-TOFHLA) as a potential health literacy screening instrument in this sample. Outcome measures included birth outcomes for the mother of hypertension, premature birth, delivery method, polyhydramnios, and vaginal laceration, and for the infant, gestational age at birth, birth weight, respiratory distress, congenital anomalies, and fetal demise. The sample was characterized with descriptive statistics. Parametric and non-parametric tests were conducted to compare levels of health literacy and birth outcomes between groups.

Results: Over 81% of the participants in this study were African American with 56.3% of the women demonstrating high health literacy as determined by the REALM. Glycemic control, measured by glucose self-report, demonstrated that women with high health literacy recorded more glucose readings (p = .02) than women with low health literacy scores. Mothers with high health literacy experienced more spontaneous labor at term (p = .10), a higher cesarean section rate and more normal weight infants than the mothers with low health literacy. While not statistically significant, women with low health literacy experienced more adverse birth outcomes. Women with pregestational diabetes trended toward higher health literacy than did women with gestational diabetes on all three instruments. In fact, those with gestational diabetes initiated prenatal care later than those with pregestational diabetes. The 3 questions from the S-TOFHLA did not show high enough correlation to the REALM (r = -.25) and thus were not considered as an effective as a screening tool for health literacy in this study.

Conclusions: In our small sample, higher health literacy was associated with more glucose readings by maternal self-report and more spontaneous labor at term. A better understanding of health literacy and its’ role in maintaining health, specifically in relation to the health of pregnant women with diabetes, is needed by health providers as this knowledge may improve birth outcomes. These results need to be interpreted cautiously because of the small sample size and further research is needed.