{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T19:54:11Z","timestamp":1782849251180,"version":"3.54.5"},"reference-count":22,"publisher":"Public Library of Science (PLoS)","issue":"6","license":[{"start":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T00:00:00Z","timestamp":1782777600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Tuberculosis (TB) remains a critical public health challenge in India, where sustained patient engagement is essential for its effective management. Despite the pivotal role of health literacy, the ability to access, understand, appraise, and apply health-related information in treatment adherence and outcomes, few tools are TB specific, culturally attuned to India, and psychometrically validated. The Health Literacy Instrument for Adults (HELIA), developed in Iran, is a multidimensional, World Health Organization (WHO)-aligned measure with proven reliability and open access, making it an ideal candidate for adaptation. This study aimed to culturally adapt and validate the HELIA for use among adults receiving TB treatment in India (HELIA-TB).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>An exploratory sequential mixed-methods design was employed for the cultural adaptation and psychometric validation of the HELIA-TB in Junagadh district, Gujarat, India, between March 2024 and March 2025. The qualitative phase included expert review, forward translation, cognitive interviews with adults with TB and\u00a0 frontline\u00a0healthcare workers, back translation, and pilot testing, following international cross-cultural validation guidelines. Findings from the qualitative phase directly informed item modification, simplification of terminology, and contextual adaptation of the HELIA-TB prior to quantitative psychometric validation. The finalized instrument was subsequently administered to 393 adults with TB to assess internal consistency, test-retest reliability, content validity, and construct validity.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>HELIA-TB retained the original five domains, access, reading, understanding, appraisal, decision-making with TB specific modifications. Internal consistency and test-retest reliability were high (\u03b1\u2009=\u20090.82\u20130.89 across domains; 0.86 overall; ICC\u2009=\u20090.88), and so was content validity (S-CVI\/Ave\u2009=\u20090.92). Health literacy scores were significantly associated with treatment adherence (Cohen's\u00a0d\u2009=\u20090.89, p\u2009&lt;\u20090.001) and self-rated health (Cohen's\u00a0d\u2009=\u20090.76, p\u2009&lt;\u20090.001). No significant differences were observed by TB type or drug resistance status.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>The adapted HELIA-TB demonstrated satisfactory psychometric properties and may support assessment of health literacy and development of targeted TB care interventions in the Indian context.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0352661","type":"journal-article","created":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T19:18:30Z","timestamp":1782847110000},"page":"e0352661","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Cultural adaptation and psychometric validation of the Health Literacy Instrument for Adults with Tuberculosis (HELIA-TB) in India"],"prefix":"10.1371","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2439-7666","authenticated-orcid":true,"given":"Arohi","family":"Chauhan","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kapil","family":"Govani","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jaya Singh","family":"Kshatri","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sandeep","family":"Chauhan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Punit","family":"Patel","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joseph","family":"Baluku","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7702-3671","authenticated-orcid":true,"given":"Abhinav","family":"Sinha","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1022-8637","authenticated-orcid":true,"given":"Marjan","family":"Van Den Akker","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jesse","family":"Jansen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jose","family":"Valderas","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sanghamitra","family":"Pati","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,6,30]]},"reference":[{"key":"pone.0352661.ref001","volume-title":"India TB Report 2024","author":"Central TB Division, Ministry of Health and Family Welfare, Government of India","year":"2024"},{"issue":"1","key":"pone.0352661.ref002","doi-asserted-by":"crossref","first-page":"453","DOI":"10.1186\/s12889-024-17828-z","article-title":"Landscaping tuberculosis multimorbidity: findings from a cross-sectional study in India","volume":"24","author":"A Chauhan","year":"2024","journal-title":"BMC Public Health"},{"issue":"6","key":"pone.0352661.ref003","doi-asserted-by":"crossref","first-page":"421","DOI":"10.2471\/BLT.23.290396","article-title":"Health literacy and tuberculosis control: systematic review and meta-analysis","volume":"102","author":"A Chauhan","year":"2024","journal-title":"Bull World Health Organ"},{"issue":"4","key":"pone.0352661.ref004","first-page":"743","article-title":"Health literacy and chronic disease management: drawing from expert knowledge to set an agenda","volume":"32","author":"I Poureslami","year":"2017","journal-title":"Health Promot Int"},{"issue":"1","key":"pone.0352661.ref005","doi-asserted-by":"crossref","DOI":"10.1186\/s12982-025-00624-4","article-title":"Enhancing health literacy and meaningful involvement of tuberculosis patients with multimorbidity in high burden settings: a call to action for India","volume":"22","author":"S Chauhan","year":"2025","journal-title":"Discov Public Health"},{"issue":"12","key":"pone.0352661.ref006","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2023-073181","article-title":"Unravelling the role of health literacy among individuals with multimorbidity: a systematic review and meta-analysis","volume":"14","author":"A Chauhan","year":"2024","journal-title":"BMJ Open"},{"key":"pone.0352661.ref007","doi-asserted-by":"crossref","first-page":"658","DOI":"10.1186\/1471-2458-13-658","article-title":"The grounded psychometric development and initial validation of the Health Literacy Questionnaire (HLQ)","volume":"13","author":"RH Osborne","year":"2013","journal-title":"BMC Public Health"},{"key":"pone.0352661.ref008","doi-asserted-by":"crossref","DOI":"10.1071\/PY22280","article-title":"Health literacy measurement: a comparison of four widely used health literacy instruments (TOFHLA, NVS, HLS-EU and HLQ) and implications for practice","volume":"30","author":"RL Jessup","year":"2024","journal-title":"Aust J Prim Health"},{"key":"pone.0352661.ref009","doi-asserted-by":"crossref","first-page":"215","DOI":"10.1186\/s12889-015-1551-6","article-title":"A critical review of population health literacy assessment","volume":"15","author":"D Guzys","year":"2015","journal-title":"BMC Public Health"},{"issue":"1","key":"pone.0352661.ref010","doi-asserted-by":"crossref","first-page":"545","DOI":"10.1186\/s12879-019-4168-z","article-title":"Chinese health literacy scale for tuberculosis patients: a study on development and psychometric testing","volume":"19","author":"Y Li","year":"2019","journal-title":"BMC Infect Dis"},{"key":"pone.0352661.ref011","doi-asserted-by":"crossref","first-page":"1207","DOI":"10.1186\/1471-2458-14-1207","article-title":"The evolution of health literacy assessment tools: a systematic review","volume":"14","author":"SV Altin","year":"2014","journal-title":"BMC Public Health"},{"issue":"1","key":"pone.0352661.ref012","doi-asserted-by":"crossref","first-page":"656","DOI":"10.1186\/s12889-020-08787-2","article-title":"Development and validation of a short and easy-to-use instrument for measuring health literacy: the Health Literacy Instrument for Adults (HELIA)","volume":"20","author":"M Tavousi","year":"2020","journal-title":"BMC Public Health"},{"key":"pone.0352661.ref013","volume-title":"Health literacy toolkit for low- and middle-income countries","author":"World Health Organization","year":"2014"},{"key":"pone.0352661.ref014"},{"key":"pone.0352661.ref015","volume-title":"Assessing the face, content, and construct validity of the Florida Questionnaire for Situational Information: observations of two expert panels","author":"J Agosta","year":"2008"},{"issue":"4","key":"pone.0352661.ref016","doi-asserted-by":"crossref","first-page":"459","DOI":"10.1002\/nur.20199","article-title":"Is the CVI an acceptable indicator of content validity? Appraisal and recommendations","volume":"30","author":"DF Polit","year":"2007","journal-title":"Res Nurs Health"},{"issue":"4","key":"pone.0352661.ref017","doi-asserted-by":"crossref","first-page":"230","DOI":"10.1089\/pop.2015.0163","article-title":"The emerging role of health literacy in chronic disease management: the response to a call for action in Canada","volume":"19","author":"I Poureslami","year":"2016","journal-title":"Popul Health Manag"},{"issue":"8","key":"pone.0352661.ref018","doi-asserted-by":"crossref","first-page":"1401","DOI":"10.3390\/medicina59081401","article-title":"Relationship between treatment burden, health literacy, and medication adherence in older adults coping with multiple chronic conditions","volume":"59","author":"D Selvakumar","year":"2023","journal-title":"Medicina (Kaunas)"},{"issue":"7","key":"pone.0352661.ref019","doi-asserted-by":"crossref","first-page":"1079","DOI":"10.1016\/j.pec.2016.01.020","article-title":"Health literacy and adherence to medical treatment in chronic and acute illness: a meta-analysis","volume":"99","author":"TA Miller","year":"2016","journal-title":"Patient Educ Couns"},{"issue":"1","key":"pone.0352661.ref020","doi-asserted-by":"crossref","first-page":"690","DOI":"10.1186\/s12889-020-08804-4","article-title":"Health literacy and its effect on chronic disease prevention: evidence from China\u2019s data","volume":"20","author":"L Liu","year":"2020","journal-title":"BMC Public Health"},{"issue":"4","key":"pone.0352661.ref021","article-title":"Community-based strategies for tuberculosis prevention and control: synergistic approach in reaching all levels of society","volume":"46","author":"A Pratama","year":"2024","journal-title":"J Public Health (Oxf)"},{"key":"pone.0352661.ref022","doi-asserted-by":"crossref","first-page":"268","DOI":"10.1080\/10810730.2011.604388","article-title":"Health literacy explains racial disparities in diabetes medication adherence","volume":"16","author":"CY Osborn","year":"2011","journal-title":"J Health Commun"}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0352661","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T19:18:35Z","timestamp":1782847115000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0352661"}},"subtitle":[],"editor":[{"given":"Muhammad Haroon","family":"Stanikzai","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,6,30]]},"references-count":22,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2026,6,30]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0352661","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,30]]}}}