Cross-cultural Adaptation and Psychometric Validation of 3 Health Literacy Instruments (SAHL-E, AAHLS, and HLS-EU-Q47) in Hindi Among Rural Adults in North India

OBJECTIVES: Health literacy (HL) is a key determinant of health behaviors and health outcomes. However, the lack of validated Hindi-language instruments limits its assessment in India. This study aimed to translate, culturally adapt, and psychometrically validate 3 internationally recognized tools-the Short Assessment of Health Literacy in English (SAHL-E), the All Aspects of Health Literacy Scale (AAHLS), and the European Health Literacy Survey Questionnaire (HLS-EU-Q47)-for Hindi-speaking adults in rural North India. METHODS: A community-based cross-sectional study enrolled 250 adults from 5 villages in Uttar Pradesh. Translation followed forward-backward procedures with expert review and pretesting. Psychometric evaluation included internal consistency (Cronbach α), test-retest reliability (intraclass correlation coefficients, ICC), construct validity (exploratory factor analysis), convergent and known-groups validity, and feasibility indicators (completion rates and interview duration). RESULTS: All instruments demonstrated strong psychometric performance. Cronbach α values were 0.84 (SAHL-E), 0.87 (AAHLS), and 0.93 (HLS-EU-Q47), and ICCs ranged from 0.86 to 0.94. Factor structures aligned with theoretical expectations. Convergent correlations ranged from 0.42 to 0.61 (p<0.001), and known-groups validity analyses showed significant differences according to education and occupation. Completion rates exceeded 98%, and the mean interview duration was approximately 32 minutes. CONCLUSIONS: The Hindi-adapted SAHL-E, AAHLS, and HLS-EU-Q47 demonstrated strong reliability, validity, and feasibility for assessing HL among rural adults in India.