Longitudinal Associations Among Maternal Health Literacy, Psychological Empowerment and Health‐Promoting Behaviours in Rural Pregnant Women: A Cross‐Lagged Panel Study

AIMS: To examine longitudinal associations among maternal health literacy, psychological empowerment and health-promoting behaviours across pregnancy among rural pregnant women. DESIGN: Prospective cohort study. METHODS: Between 1 May 2023 and 15 January 2024, 694 rural pregnant women were assessed at 12, 24 and 32 gestational weeks (T1, T2 and T3). Descriptive, correlation and cross-lagged panel analyses were used. RESULTS: Significant reciprocal cross-lagged associations were observed among maternal health literacy, psychological empowerment and health-promoting behaviours across pregnancy. Maternal health literacy at T1 significantly predicted psychological empowerment at T2 (β = 0.183, B = 0.056, 95% CI [0.036, 0.075], p < 0.001), and psychological empowerment at T2 predicted health-promoting behaviours at T3 (β = 0.256, B = 0.373, 95% CI [0.246, 0.500], p < 0.001). Longitudinal indirect pathway analysis showed that maternal health literacy at T1 was indirectly associated with health-promoting behaviours at T3 through psychological empowerment at T2 (β = 0.047, B = 0.021, 95% CI [0.010, 0.031], p < 0.001). CONCLUSION: Maternal health literacy, psychological empowerment, and health-promoting behaviours were longitudinally and reciprocally associated across pregnancy. Psychological empowerment also carried the longitudinal indirect association between earlier maternal health literacy and later health-promoting behaviours. Early gestation may represent an intervention window. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Integrating literacy-sensitive and empowerment-based interventions into antenatal care may help rural pregnant women support sustained health-promoting behaviours throughout pregnancy. IMPACT: Clarifies the longitudinal role of maternal health literacy. Demonstrates a significant indirect longitudinal role of psychological empowerment. Supports early-stage capability-based interventions within rural maternal healthcare. REPORTING METHOD: This study is consistent with the STROBE statement for cohort studies. PATIENT OR PUBLIC CONTRIBUTION: This study did not include patient or public involvement in its design, conduct or reporting.