Development and Validation of the BEEA-C: A TDF-based Exercise Adherence Checklist for Chronic Low Back Pain in a Multilingual Indian Population

Background: Exercise is the cornerstone of chronic low back pain (CLBP) management, yet long-term adherence remains poor. Up to 70% of individuals with CLBP fail to adhere to prescribed home exercise programmes, and the multilingual, socioculturally diverse Indian population faces unique contextual barriers and enablers not captured by existing Western-derived instruments. No validated tool exists to systematically assess these factors in Indian CLBP populations. Objective: To develop and psychometrically validate a Theoretical Domains Framework-based Barriers and Enablers to Exercise Adherence Checklist (BEEA-C) for individuals with CLBP. Methods: Item generation was performed through systematic review synthesis (Gilanyi et al., 2024), expert panel review ( n = 12) and patient focus groups ( n = 20). The draft checklist underwent forward-backwards translation into Hindi, Gujarati and Marathi. Content validity was assessed by a 10-member expert panel, yielding an item-level content validity index (I-CVI) and scale-level CVI (S-CVI/Ave). Cognitive debriefing ( n = 30) preceded the main validation study. A cross-sectional survey was conducted among 320 adults with CLBP attending the physiotherapy outpatient department (OPD). Exploratory factor analysis (EFA), confirmatory factor analysis (CFA), internal consistency (Cronbach’s alpha, McDonald’s omega), test–retest reliability intraclass correlation coefficient [ICC (2,1)]) and construct validity (convergent, divergent) were assessed. Results: The final BEEA-C comprised 48 items across four domains: (a) Exercise, Pain and Body (12 items), (b) Psychological Factors (14 items), (c) Social Factors (10 items) and (d) External Factors (12 items). S-CVI/Ave was 0.94. EFA revealed a four-factor solution explaining 62.3% of the variance. CFA confirmed adequate fit (CFI = 0.96, RMSEA = 0.057, SRMR = 0.061). Cronbach’s alpha ranged from 0.81 to 0.91 across subscales; ICC(2,1) = 0.89 (95% CI: 0.85–0.92). Convergent validity with the Brief Pain Inventory and Fear-avoidance Beliefs Questionnaire was satisfactory. Conclusion: The BEEA-C is a reliable, valid and culturally appropriate tool for identifying barriers and enablers to exercise adherence in multilingual Indian CLBP populations. It has direct clinical utility for individualised exercise prescription and adherence intervention planning.