Cultural adaptation and validity testing of the Health Literacy Questionnaire (HLQ) in Hindi in northern India

Background Health literacy is an important determinant of health. To assess health literacy, the Health Literacy Questionnaire (HLQ) was developed in 2013 in Australia. However, for the 9-scale HLQ to be used in a different socio-cultural environment, it is necessary to culturally adapt and test the questionnaire before implementation. This study aimed to adapt the HLQ to Hindi and evaluate its psychometric properties in an Indian rural, resource-poor setting, the Chandigarh Union Territory. Methods The translation was guided by the Translation Integrity Protocol, followed by a consensus meeting with the HLQ developer. Cognitive interviews were undertaken to collect validity evidence on response process. A cross-sectional survey was then conducted to evaluate the psychometric properties, including internal structure and reliability, of the HLQ Hindi version. Results Cognitive interviews (n = 10) results indicated that revision to one term was required. A total of 260 adults participated in the survey (mean age: 36.9 years) with 61.5% being women. All one-factor confirmatory factor models demonstrated satisfactory to reasonable fit except Scale 3 ‘Actively managing my health’ which achieved excellent fit following model adjustment. Factor loadings were all > 0.60 except for three items. The nine-factor model demonstrated close fit (χ² WLSMV (866) = 1371, p = 0.000, CFI = 0.970, TLI = 0.967, RMSEA = 0.047, SRMR = 0.053). Insufficient discriminant validity was observed among most of the nine factors. Reliability was good, with Raykov’s composite reliability > 0.70 for Scales 1 to 5 and > 0.80 for Scales 6 to 9. Conclusions The culturally adapted HLQ Hindi version was found to have strong psychometric properties in the Indian rural setting. It will be a valuable needs assessment tool to improve health equity and outcomes.