Brief estimate of health knowledge and action – HIV version: psychometric assessment

Abstract

Objective  To perform cross-cultural adaptation and psychometric evaluation of the Brief Estimate of Health Knowledge and Action (BEHKA)—HIV Version questionnaire for use in Brazil.

Methods  Two-stage psychometric study. In the first stage, cross-cultural adaptation was performed. Translators, back-translators, a committee of experts, and people living with HIV participated. Kappa and content validity coefficients were calculated. In the second stage, psychometric evaluation was performed using exploratory factor analysis, discriminant analysis, Spearman’s Rho correlation, and network analysis.

Results  The agreement among judges was high (k=1.0) with an adequate content validity coefficient (CVC=0.96). The instrument showed internal validity, with Kayser-Meyer-Olkin (KMO = 0.53) and Bartlett’s sphericity test significant. Network analysis showed strong relationships between questions in the same domain. Discriminant analysis showed adequate indicators in Spearman’s Rho correlation and network analysis.

Conclusion  The questionnaire (BEHKA)—HIV Version shows evidence of validity for use in Brazil. The identification of factors related to adherence and treatment promotes health literacy and can contribute to practices and policies aimed at the prevention and clinical management of HIV/AIDS.

Keywords:
Validation studies; Health literacy; HIV; Health education; Public health

Resumo

Objetivo  Realizar a adaptação transcultural e avaliação psicométrica do questionário Brief Estimate of Health Knowledge and Action (BEHKA)—HIV Version para uso no Brasil.

Métodos  Estudo psicométrico em duas etapas. Na primeira etapa, foi realizada a adaptação transcultural. Participaram tradutores, retrotradutores, comitê de especialistas e pessoas que vivem com HIV. Foram calculados os coeficientes de Kappa e de validade de conteúdo. Na segunda etapa, foi realizada a avaliação psicométrica, utilizando a análise fatorial exploratória, análise discriminante, correlação Rho de Spearman e análise de rede.

Resultados  A concordância entre os juízes foi alta (k=1,0) com coeficiente de validade do conteúdo adequado (CVC=0,96). O instrumento apresentou validade interna, com Kayser-Meyer-Olkin (KMO = 0,53) e teste de esfericidade de Bartlett significante. A análise de rede evidenciou fortes relações entre questões do mesmo domínio. A análise discriminante apresentou indicadores adequados na correlação Rho de Spearman e na análise de rede.

Conclusão  O questionário (BEHKA)—HIV Version apresenta evidências de validade para utilização no Brasil. A identificação de fatores relacionados a adesão e o tratamento favorecem o letramento em saúde e pode contribuir com práticas e políticas voltadas a prevenção e manejo clínico do HIV/aids.

Descritores:
Estudos de validação; Letramento em saúde; HIV; Educação em saúde; Saúde pública

Resumen

Objetivo  Realizar la adaptación transcultural y la evaluación psicométrica del cuestionario Brief Estimate of Health Knowledge and Action (BEHKA) – HIV Version para su uso en Brasil.

Métodos  Estudio psicométrico en dos etapas. En la primera etapa, se realizó la adaptación transcultural. Participaron traductores, retrotraductores, un comité de especialistas y personas que viven con el VIH. Se calcularon los coeficientes de Kappa y de validez de contenido. En la segunda etapa, se realizó la evaluación psicométrica, utilizando el análisis factorial exploratorio, el análisis discriminante, la correlación Rho de Spearman y el análisis de red.

Resultados  La concordancia entre los jueces fue alta (k=1,0) con un coeficiente de validez de contenido adecuado (CVC=0,96). El instrumento presentó validez interna, con Kayser-Meyer-Olkin (KMO = 0,53) y prueba de esfericidad de Bartlett significativa. El análisis de red evidenció fuertes relaciones entre cuestiones del mismo dominio. El análisis discriminante presentó indicadores adecuados en la correlación Rho de Spearman y en el análisis de red.

Conclusión  El cuestionario BEHKA – Versión VIH presenta evidencia de validez para su uso en Brasil. La identificación de factores relacionados con la adherencia y el tratamiento favorece la alfabetización en salud y puede contribuir a prácticas y políticas orientadas a la prevención y el manejo clínico del VIH/sida.

Descriptores:
Estudios de validación; Alfabetización en salud; VIH; Educación en salud; Salud pública

Introduction

Health literacy (HL) is understood as the set of knowledge and skills acquired throughout life that enable individuals to access, understand, evaluate, and use health information and services, promoting actions for individual and collective care. However, this concept goes beyond the simple transmission of information, as it also involves the development of critical skills that enable people to make conscious and informed decisions about their health, considering the social determinants that influence their access to health services.(¹)

HL is essential for individuals to adopt preventive behaviors and maintain self-care practices, which directly contributes to improving the health indicators of the population. In this sense, it plays a central role in promoting health equity, especially in more vulnerable groups, such as people living with HIV (PLHIV). For these individuals, HL can be decisive in treatment adherence, continuity of care, and prevention of new infections. However, the development of HL is influenced by structural and contextual factors that need to be considered in public policies and educational strategies.(²)

The HL of PLHIV is affected by several barriers, such as stigma associated with their health condition, self-efficacy, and trust in health professionals—factors that directly influence adherence to antiretroviral therapy (ART) and continuity of care.(²) In addition, PLHIV face structural barriers, such as racism, homophobia, and social inequality, which hinder access to health services and compromise the quality of care provided. These barriers also impact knowledge about preventive measures, such as pre-exposure prophylaxis (PrEP), and consequently reduce the ability of PLHIV to exercise autonomy over their treatment and health.(³)

In Brazil, a study revealed that PLHIV with inadequate HL have insufficient medication adherence compared to those with adequate HL (Prevalence Ratio = 1.17).(⁴) These data reinforce the importance of identifying and working with HL in a personalized way, especially in populations that already face social and economic vulnerabilities. However, Brazil still lacks public policies that incorporate the concept of social support as a strategy for HIV control, in addition to not having population data on social support, which limits the creation of specific measures for this population.

Although the country has made commitments to the United Nations (UN) 2030 Agenda, including Sustainable Development Goal (SDG) 3, which aims to eliminate HIV/AIDS by 2030,(⁵) there is a mismatch between these commitments and the reality of national public policies. The absence of specific instruments to measure the HL of PLHIV in Brazil is a significant gap that may limit the ability of health services to implement educational interventions and personalized care strategies.

In this context, the study aims to perform the cross-cultural adaptation and psychometric evaluation of the Brief Estimate of Health Knowledge and Action (BEHKA)—HIV Version questionnaire for use in Brazil. The instrument aims to assist health professionals in identifying the HL of PLHIV and in developing more effective educational strategies that contribute to improving treatment adherence, promoting self-care, and controlling the HIV/AIDS epidemic in the country.

Métodos

This is a psychometric study of cross-cultural adaptation to Brazilian Portuguese and psychometric evaluation of the Brief Estimate of Health Knowledge and Action – HIV Version (BEHKA-HIV), aiming to measure HL in PLHIV. Conducted in two stages: cross-cultural adaptation,(⁶,⁷) followed by application to 356 PLHIV to verify psychometric properties. The standards of the American Educational Research Association (AERA), the American Psychological Association (APA), and the National Council on Measurement in Education (NCME) were followed.(⁸)

The data collection was carried out in Recife, Pernambuco, Brazil, with the original author’s permission granted by email. The cross-cultural adaptation stage began with the adaptation of the original instrument by two bilingual translators (Portuguese-English), both native Portuguese speakers, one of whom had knowledge in the field of health. A third translator, whose native language was Portuguese, synthesized the translations. Two translators whose native language was English, who were unfamiliar with the original instrument and the concepts explored and had no training in the health field, performed the back-translation.(⁶,⁷)

Next, the evaluation was carried out by a committee of experts in two rounds. The first was asynchronous, via Google Forms, and consisted of an expert in the method and seven health professionals, all translators and back-translators. The second round was synchronous, via Google Meets, in which all topics and responses from the online form were discussed, with an emphasis on the gaps that were generated, resolving them and finalizing the final product of the cross-cultural adaptation stage. The psychometric evaluation was conducted in two Specialized Care Services (SCS 01 and SCS 02), the main locations for care for PLHIV in Pernambuco.

The translations took place between April and May 2022. The judges’ analysis took place in two rounds: the first between September 2022 and January 2023 (asynchronous), and the second in February 2023 (synchronous). The pre-test was conducted between March 31 and April 25, 2023, followed by the psychometric evaluation conducted between May and June 2023.

Five translators and one rapporteur participated in the cross-cultural adaptation stage. Seven experts participated in the first round of the judging committee, and 13 participated in the second round (five translators, one method expert, and seven other experts). In the psychometric evaluation, the pretest was applied to 41 PLHIV to verify the properties based on the internal structure and relationships with external variables. The instrument was applied to 356 PLHIV who did not participate in the pretest.

The sample was defined based on the recommended methodological approach, considering translators, specialists, and the target population.(⁶,⁷) In the psychometric evaluation, the Kaiser-Meyer-Olkin (KMO) sample adequacy test and the Measure Sample Adequacy (MSA) calculation were used, with minimum parameters of 0.70 for KMO and 0.50 for MSA.(⁸) The sample of 356 participants was considered adequate.

The translators were selected for convenience, considering their experience with the method adopted. For the experts, Fehring’s criteria were applied.(⁹) The Committee included health professionals with doctoral or postdoctoral degrees, specialized technical knowledge in HIV, and publications in the field. Individuals ≥ 18 years of age, who spoke Brazilian Portuguese, and had been undergoing treatment for ≥ 2 months were included in the pretest and psychometric evaluation. Individuals unable to give consent, illiterate individuals, or individuals with uncorrectable visual/hearing impairments were excluded.

Data collected from experts: semantic, idiomatic, experiential, and conceptual equivalence. In the pre-test: clarity of language and practical relevance. In the psychometric evaluation: questions related to knowledge (Part I) and action (Part II). For discriminant validation: intermediation, proximity, strength, and influence.

The BEHKA-HIV was developed in the United States in 2001, initially with 34 items, based on the Rapid Estimate of Adult Literacy in Medicine (REALM), and adapted to 8 items in 2007, with two subscales: knowledge (3 items) and action (5 items), with Cronbach’s alpha of 0.73 (knowledge) and 0.79 (action). Compared to REALM, it predicted medication adherence (sensitivity 0.76, specificity 0.82). The scores assessed by the instrument are: 0-3 (low HL), 4-5 (marginal HL), 6-8 (adequate HL).(¹⁰)

In addition to BEHKA, the life satisfaction scale (ESV) was used to verify discriminant validity.

The adaptation was performed by two bilingual translators (Portuguese-English), who produced two versions. The synthesis was done by a third bilingual translator, followed by back-translation by two bilingual translators (English-Portuguese). The expert committee evaluated two rounds. The pretest was applied to 41 PLHIV, and the final version and adaptation reports were sent to the original author of the instrument, and the final version was submitted for psychometric evaluation.

The Kappa agreement coefficient was calculated, considering values closer to 1 as adequate.(¹¹,¹²) In the pre-test, the content validity coefficient (CVC) was used, considering CVC > 0.80 per item to be valid.(¹³) The CVC was used to assess the clarity of language and practical relevance of the instrument.

Exploratory Factor Analysis (EFA) was performed using the Weighted Least Squares (WLS) method, with Bartlett’s and KMO sphericity tests.(⁸)To complete the psychometric analysis of the instrument, evidence of validity was sought based on external measures using Spearman’s Rho correlation and network analysis between BEHKA and ESV. As this is an innovative instrument in Brazil, there are no convergent measures that can be used. To confirm the structure, we opted to perform a Network Analysis (NA), suitable for polytomous categorical variables. The analysis was performed using RStudio software version 2022.02. (Annex 1).

The study was approved by the Research Ethics Committee (REC), under opinion No. 5,178,337 (Certificate of Ethical Review: 53094621.7.0000.5192), dated December 20, 2021.

Results

After each stage of adaptation of the instrument, a thorough analysis of the terms and reports issued by the translators was carried out, supporting the two rounds of the judging committee. Terms considered to be discrepancies during the translations were listed on a form for evaluation and suggestions by the judges. In the adaptation and synthesis stages, no discrepancies were identified between the translators. In the back-translation, suggestions were made, such as replacing ‘estimate’ with ‘test on’. In item 3, the term ‘medication’ was used as an uncountable noun. In ‘Tell me if you agree...,’ the option ‘each of the 5 statements below’ was chosen. In question 3, it was recommended to replace ‘sad and down’ with just ‘down’. The second back-translator focused on simplifying cultural terms, such as ‘go up/go down’. Once the translations and back-translations were completed, the first round of the judging committee took place asynchronously, with invitations sent to 25 researchers and 8 valid forms returned. Suggestions included replacing ‘HAART’ with ‘medications to treat HIV’ and changing ‘medications’ to ‘medicines’. And in the second part, in question 01, it was proposed to change ‘... When they make me feel sick” to “I don’t take my medication when it makes me feel sick.” As for experiential and conceptual equivalences, there was agreement among the judges. After compiling the data, a report with suggestions was generated and sent to the participants in the second round for reading and recommendations. The second round was conducted synchronously to resolve disagreements. During the online meeting, the discrepant terms were discussed, and the judges scored their observations. Terms such as “Increase or Decrease” in questions 1b, 2a, and 2b were accepted as appropriate. In question 3, the use of “antiretroviral therapy” was chosen. Idiomatic equivalence reiterated these changes. After the two rounds of the committee, the disagreements were resolved, and the Kappa coefficient was calculated, which presented almost perfect values, indicating a high degree of agreement among evaluators, as shown in Table 1.

Table 1
Verification of agreement among judges using Kappa analysis

	Judge 1	Judge 2	Judge 3	Judge 4	Judge 5	Judge 6	Judge 7
Judge 1
Judge 2	0.907*
Judge 3	0.840*	0.841*
Judge 4	0.976*	0.930*	0.862*
Judge 5	0.976*	0.930*	0.862*	1.0*
Judge 6	0.976*	0.930*	0.862*	1.0*	1.0*
Judge 7	0.976*	0.930*	0.862*	1.0*	1.0*	1.0*
Judge 8	0.976*	0.930*	0.862*	1.0*	1.0*	1.0*	1.0*

• *p-value < 0,001

To assess content validity (n=41), PLHIV were interviewed at both SAEs, with 73.1% (n=30) being male and 26.8% (n=11) female. The content validity coefficient is shown in Table 2.

Table 2
Presentation of content validity coefficients by item

Item	Clarity of language	Practical relevance
Part I	0.99	0.96
1A	0.94	0.97
1B	0.92	0.99
2A	0.97	0.97
2B	0.93	0.95
Part II	0.98	0.98
1	0.99	0.97
2	0.99	0.97
3	0.99	0.97
4	0.99	0.97
5	0.99	0.99

To assess the internal structure validity of the instrument, CFA was performed using the WLS method. The results showed adequacy for analysis, with KMO = 0.53 and Bartlett’s sphericity test significant [χ²(45) = 3223.173; p < 0.001], in addition to MSA > 0.50 per item. The rotated factor loadings (promax rotation) for each factor and the composite reliability values for each factor are shown in Table 3.

Table 3
Presentation of factor loadings from exploratory factor analysis – structural matrix

Items	Factor 1	Factor 2
PARTI-1A	0.883
PARTI-1B	-0.889
PARTI-2A	0.843
PARTI-2B	-0.842
PART1-3	0.423
PARTII-1		0.411
PARTII-2		0.42
PARTII-3		0.506
PARTII-4		0.526
PARTII-5		0.539
CR*	0.892	0.601
CR total	0.875
Eigenvalue	2.951	1.220
Explained variance	29.50%	12.20%
Total explained variance	41.70%

• Promax rotation applied; *CR: Composite Reliability

The network analysis presents evidence of internal validity, identifying 10 nodes and 45 edges. The level of distance was 0.00, indicating greater network strength the closer to zero. To verify external validity, Spearman’s nonparametric correlation (Rho) was performed. As the instrument is innovative in Brazil, there are no convergent measures available. Therefore, discriminant analysis was applied, which showed that BEHKA did not present strong correlations with ESV. (Table 4).

Table 4
Spearman’s Rho correlation for evidence of validity based on external measures, using the life satisfaction scale

	ESV1*	ESV2*	ESV3*	ESV4*	ESV5*	Total ESV†	Score ESV†
Part I-1a‡	0.037	0.003	0.044	0.098	0.052	0.041	-0.039
Part I-1b‡	-0.04	-0.008	-0.053	-0.106§	-0.06	-0.049	0.047
Part I-2a‡	-0.08	-0.048	-0.095	-0.024	0.009	-0.077	0.068
Part I-2b‡	0.086	0.036	0.071	0.008	-0.023	0.06	-0.051
Part I-3‡	0.063	0.109§	0.135§	0.151||	0.091	0.137§	-0.141§
Part II-1‡	0.096	0.145§	0.037	0.075	0.051	0.105§	-0.112§
Part II-2‡	0.047	0.078	0.082	0.057	0.118§	0.104	-0.107§
Part II-3‡	-7.09E-01	0.098	0.141§	0.098	-0.013	0.087	-0.091
Part II-4‡	0.063	0.094	0.048	0.06	-0.001	0.074	-0.073
Part II-5‡	0.056	0.092	-0.011	0.045	0.01	0.059	-0.055
Score 1	0.038	-0.003	-0.005	-0.062	-0.064	-0.009	0.015
Score 2	0.106	0.172||	0.064	0.094	0.055	0.135§	-0.138§
Total	0.075	0.068	0.029	-0.016	-0.031	0.05	-0.046
Score	0.101	0.093	0.07	0.022	0.01	0.101	-0.095

• *ESV = items from the life satisfaction scale; †ESV = life satisfaction scale; ‡questions from the Brief Estimate of Health Knowledge and Action scale; §probability of significance ≤ 0.05; ||probability of significance ≤ 0.005

In the network analysis between BEHKA-HIV and ESV, 15 nodes and 105 edges were identified, with a distance level of 0.00. The network centrality measures are shown in Table 5.

Table 5
Centrality measures of network analysis to verify discriminant validity

Network
Variable	Intermediation	Proximity	Strength	Influence
Part I-1a*	1.034	0.291	-0.190	0.270
Part I-1b*	-0.782	-0.205	0.383	0.582
Part I-2a*	-0.782	-1.705	-1.310	-1.594
Part I-2b*	-0.782	-0.205	0.383	0.582
Part I-3*	1.453	1.224	0.669	-1.453
Part II-1*	-0.503	0.104	0.153	0.133
Part II-2*	-0.084	0.507	0.605	1.005
Part II-3*	1.173	1.310	1.343	0.582
Part II-4*	-0.782	0.421	0.213	1.687
Part II-5	2.151	1.498	1.970	1.168
SV1†	-0.782	-1.697	-1.415	-1.003
SV2†	-0.223	0.048	-0.173	-0.039
SV3†	0.475	0.396	-0.049	-0.081
SV4†	-0.782	-0.933	-1.186	-0.521
SV5†	-0.782	-1.054	-1.395	-1.317

• *Questions from the Brief Estimate of Health Knowledge and Action scale; †ESV= items from the life satisfaction scale

Discussion

The cross-cultural adaptation and validation of BEHKA-HIV represents a significant contribution by offering a potentially useful tool in clinical practice, especially for nurses, by supporting the development of personalized educational actions for PLHIV.(¹⁴) The adaptation was conducted with methodological rigor, respected Brazilian cultural diversity, and ensured linguistic uniformity. In addition, in the second round of the judging committee, discrepancies in terminology were clarified, ensuring clarity and understanding of the items. The high Kappa agreement coefficient reinforced the agreement among the evaluators.(¹⁵,¹⁶)

In the pre-test, the clarity of language and practical relevance were confirmed by the CVC, with all items scoring above 0.80, demonstrating the validity of the instrument for measuring issues related to HL in the context of HIV in Brazil.(¹³,¹⁷,¹⁸) Psychometric analyses also demonstrated the validity of the instrument for national use, allowing health professionals to personalize care, identify levels of HL, and implement more effective educational strategies.

Controlling HIV infection as a public health problem requires biomedical, structural, and behavioral measures. The increase in new cases reinforces the need to understand the structural and care factors that impact treatment. Adherence to antiretroviral therapy and the application of the continuum of care are essential to prevent new infections and control the disease.(¹⁹) The use of instruments such as BEHKA-HIV is highly relevant for people who require prolonged treatment, such as PLHIV.

Brazilian studies indicate that PLHIV with adequate HL show greater adherence to ART, greater self-care, and better health outcomes, while those with insufficient HL face barriers to treatment adherence. However, the instruments used in these studies only assessed functional literacy, highlighting the need for tools that are more specific to the demands of this population.(⁴,²⁰) In Brazil, there is a shortage of instruments that assess HIV-specific HL, and multidimensional tools are essential for personalizing care and broadening understanding of the needs of PLHIV.

The application of BEHKA-HIV has the potential to impact the health care of PLHIV, both in clinical settings and in educational practices. In the clinical context, it can be used as a rapid diagnostic tool to assess HL and personalize educational interventions according to individual needs. In primary care, it can be applied during routine consultations to identify patients with low HL, enabling personalized care plans that reinforce ART adherence and self-care.(¹⁶,²¹)

In SAEs, BEHKA-HIV can assist multidisciplinary follow-up by identifying difficulties in understanding prescriptions, managing adverse effects, and adhering to preventive measures such as PrEP. In hospitals, the tool can be used to identify specific educational needs prior to discharge, reducing readmissions related to treatment failures and ensuring proper management after returning home.(²²,²³)

Furthermore, in the educational sphere, BEHKA-HIV is valuable in programs aimed at healthcare professionals, people living with HIV, and their communities. In training and capacity-building programs for professionals such as doctors, nurses, and community health workers, it can guide educational practices tailored to patients’ difficulties, promoting clear and accessible guidance through strategies such as the use of simplified language, visual materials, and practical demonstrations.(²⁴)

The integration of BEHKA-HIV reinforces the central role of health professionals in developing HL and promoting self-care among PLHIV. Trained professionals help people improve their quality of life and manage their care on an ongoing basis.(²⁵-²⁷) The integration of HL into the care of PLHIV promotes self-care and quality of life, aligning with the principles of salutogenesis.(²⁸)

From the perspective of salutogenesis, health is a continuous learning process that occurs through the improvement of the HL, which enables people to understand health resources and address treatment needs.(²⁷) Thus, the development of autonomy and proactive action for maintaining health is especially relevant in the treatment of HIV, promoting adherence to ART, maintaining undetectable viral load, and reducing comorbidities, hospitalizations, and new cases of infection.(²⁸-³⁰)

Although healthcare is multidimensional, it is essential to empower people to understand their condition and reframe vulnerable behaviors. Adherence to ART depends both on the intervention of healthcare professionals and on the awareness of the users themselves. In this sense, the use of BEHKA can contribute significantly to the development of HL, impacting healthcare decisions and expanding the reach of care goals.(⁵,²⁷)

Future research may explore the use of BEHKA-HIV in different population groups and regions of Brazil, expanding its external validity and enhancing its impact on the quality of comprehensive care for PLHIV.

Among the limitations of the study, we highlight the absence of a robust theoretical foundation to support the conceptual construction of the instrument, as well as the need for greater detail in the methodological procedures and presentation of results, an aspect that should be considered in future validations.

Conclusion

The Brief Estimate of Health Knowledge and Action – HIV Version is valid for use in Brazil, serving as a tool that can strengthen health literacy, promote adherence to treatment among PLHIV, and consequently have a positive impact on public health policies. The educational process should be continuous and occur at all levels of health care, using instruments such as BEHKA-HIV to support more effective and personalized interventions, contributing to the comprehensive care of PLHIV.

References

• ¹ World Health Organization (WHO). Health Promotion Glossary of Terms 2021. Geneva: WHO; 2021 [cited 2025 Aug 12]. Available from: https://www.who.int/publications/i/item/9789240038349
  » https://www.who.int/publications/i/item/9789240038349
• ² Mgbako O, Conard R, Mellins CA, Dacus JD, Remien RH. A systematic review of factors critical for HIV health literacy, ART adherence and retention in care in the U.S. for racial and ethnic minorities. AIDS Behav. 2022;26:3480-93.
• ³ Demeke J, Djiadeu P, Yusuf A, Whitfield DL, Lightfoot D, Worku F, et al. HIV prevention and treatment interventions for Black men who have sex with men in Canada: scoping systematic review. JMIR Public Health Surveill. 2024;10:e40493.
• ⁴ Silva MA, Lima MC, Dourado CA, Andrade MS. Aspects related to health literacy, self-care and compliance with treatment of people living with HIV. Rev Esc Enferm USP. 2022;56:e20220120.
• ⁵ Joint United Nations Programme on HIV/AIDS (UNAIDS). The path that ends AIDS: UNAIDS Global AIDS Update 2023. Geneva: Joint United Nations Programme on HIV/AIDS; 2021 [cited 2023 Apr 11]. Available from: https://thepath.unaids.org/wp-content/themes/unaids2023/assets/files/2023_report.pdf
  » https://thepath.unaids.org/wp-content/themes/unaids2023/assets/files/2023_report.pdf
• ⁶ Beaton D, Bombardier C, Guillemin F, Ferraz MB. Recommendations for the crosscultural adaptation of the DASH & QuickDASH outcome measures contributors to this document. Institute for Work & Health; 2007 [cited 2023 Apr 11]. Available from: https://dash.iwh.on.ca/sites/dash/files/downloads/cross_cultural_adaptation_2007.pdf
  » https://dash.iwh.on.ca/sites/dash/files/downloads/cross_cultural_adaptation_2007.pdf
• ⁷ Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine (Phila Pa 1976). 2000;25(24):3186-91.
• ⁸ American Psychological Association (APA). The Standards for Educational and Psychological Testing. Washington: APA; 2014 [cited 2023 Apr 11]. Available from: https://www.apa.org/science/programs/testing/standards
  » https://www.apa.org/science/programs/testing/standards
• ⁹ Fehring RJ. Methods to validate nursing diagnoses. Heart Lung. 1987;16(6 Pt 1):625-9.
• ¹⁰ Osborn CY, Davis TC, Bailey SC, Wolf MS. Health literacy in the context of HIV treatment: introducing the Brief Estimate of Health Knowledge and Action (BEHKA)-HIV version. AIDS Behav. 2010;14(1):181-8.
• ¹¹ Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psychol Bull. 1979;86(2):420-8.
• ¹² Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159-74.
• ¹³ Hernández-Nieto RA. Contributions to statistical analysis. Mérida: Universidad de Los Andes; 119 p.
• ¹⁴ Duarte FH, Araújo NM, Silva SO, Leal NT, Costa TM, Alencar IG, et al. Validação do conteúdo de um recurso audiovisual para pessoas vivendo com HIV. Acta Paul Enferm. 2024;37:eAPE01361.
• ¹⁵ McGraw KO, Wong SP. Forming inferences about some intraclass correlation coefficients. Psychol Methods. 1996;1(1):30-46.
• ¹⁶ Cohen J. A Coefficient of agreement for nominal scales. Educ Psychol Meas. 1960;20(1):37-46.
• ¹⁷ Arroio LF, Lopes JL, Barros AL, Lima EA, Lopes CT, Santos VB. Development and content validity of a website for patients with coronary artery disease. Rev Bras Enferm. 2023;76(1):e20220302.
• ¹⁸ Meneguin S, Pollo CF, Garuzi M, Morais JF, Reche MC, Melchiades EP, et al. Creation and content validity of a scale for assessing adherence to good practices for COVID-19. Rev Bras Enferm. 2022;75(5):e20210223.
• ¹⁹ Brasil. Ministério da Saúde. Secretaria de Ciência, Tecnologia, Inovação e Insumos Estratégicos em Saúde. Secretaria de Vigilância em Saúde. Protocolo Clínico e Diretrizes Terapêuticas para Profilaxia Pré-Exposição (PrEP) de Risco à Infecção pelo HIV. Brasília (DF): Ministério da Saúde; 2022 [citado 2023 Abr 25]. Disponível em: http://antigo.aids.gov.br/pt-br/pcdt
  » http://antigo.aids.gov.br/pt-br/pcdt
• ²⁰ Perez TA, Chagas EF, Pinheiro OL. Health functional literacy and adherence to antiretroviral therapy in people living with HIV. Rev Gaúcha Enferm. 2021;42:e20200012.
• ²¹ Bröder J, Chang P, Kickbusch I, Levin-Zamir D, McElhinney E, Nutbeam D, et al. IUHPE Position Statement on Health Literacy: a practical vision for a health literate world. Glob Health Promot. 2018;25(4):79-88.
• ²² Garett R, Young SD. The impact of misinformation and health literacy on HIV prevention and service usage. J Assoc Nurses AIDS Care. 2022;33(1):e1-5.
• ²³ Ousseine YM, Allaire C, Ringa V, Lydie N, Velter A. Health literacy as a mediator of the relationship between socioeconomic position and pre-exposure prophylaxis uptake among men who have sex with men living in France. Health Lit Res Pract. 2023;7(1):e61-70.
• ²⁴ Matchanova A, Sheppard DP, Medina LD, Morgan EE, Woods SP. Health literacy mediates the effects of educational attainment on online pharmacy navigation skills in older adults with HIV disease. Psychol Health. 2023;38(3):348-68.
• ²⁵ Byrne D. Understanding and mitigating low health literacy. Nurs Stand. 1987;37(10):e11875.
• ²⁶ Dyrehave C, Nielsen D, Wejse C, Maindal HT, Rodkjaer LO. Development of a complex intervention for health care professionals' care of patients with african background and HIV infection using the behavior change wheel method. J Transcult Nurs. 2022;33(3):259-67.
• ²⁷ Larsen MH, Mengshoel AM, Andersen MH, Borge CR, Ahlsen B, Dahl KG, et al. "A bit of everything": health literacy interventions in chronic conditions - a systematic review. Patient Educ Couns. 2022;105(10):2999-3016.
• ²⁸ Pinho CM, Lima MC, Silva MA, Dourado CA, Oliveira RC, Aquino JM, et al. Development and validation of an instrument for the evaluation of HIV care in Primary Health Care. Rev Bras Enferm. 2023;76(1):e20220247.
• ²⁹ Yang Y. Effects of health literacy competencies on patient-centered care among nurses. BMC Health Serv Res. 2022;22(1):1172.
• ³⁰ Mills A. Promoting health through nurse-led healthy conversations. Nurs Stand. 2023;38(10):46-50.

• Data availability:
  The survey data are available in the article.

Annex 1

The Brief Estimate of Health Knowledge and Action- HIV version (BEHKA-HIV)

Breve estimativa de conhecimentos e ações na saúde — Versão HIV (BEHKA-HIV) – Brasil
Parte I: Conhecimento - ‘‘Gostaríamos de saber se os pacientes estão familiarizados com dois termos sobre o HIV: a contagem de CD4 e a carga viral. Você se importaria se eu perguntasse algumas coisas sobre isso? OK...’’
1a. O que é a contagem de CD4?
Determine se está correto: CORRETO [1] INCORRETO [0]
1b. Se 1a estiver correto, o objetivo do tratamento é fazer com que a contagem de CD4 aumente ou diminua?
AUMENTE [1]			DIMINUA [0]
2a. O que é a carga viral?
Determine se está correto:	CORRETO [1]				INCORRETO [0]
2b. Se 2a estiver correto, o objetivo do tratamento é fazer com que a carga viral aumente ou diminua?
AUMENTE [0]			DIMINUA [1]
3. Quais são os medicamentos que você está tomando para tratar o HIV? - Para ser considerado correto, o respondente deve identificar todos os medicamentos da terapia antirretroviral-
CORRETO [1]	INCORRETO [0]			NÃO SEI [0]
Parte II: Ações — ‘‘Diga-me se você concorda, não tem certeza ou discorda das 5 afirmações a seguir:’’
1.Eu não tomo meus remédios quando eles fazem eu me sentir mal.		CONCORDO [0]			NÃO TENHO CERTEZA [0]	DISCORDO [1]
2.Eu não tomo meus remédios quando estou muito cansado.		CONCORDO [0]			NÃO TENHO CERTEZA [0]	DISCORDO [1]
3.Eu não tomo meus remédios quando me sinto triste e desanimado.		CONCORDO [0]			NÃO TENHO CERTEZA [0]	DISCORDO [1]
4.Eu não tomo meus remédios porque eles têm gosto ruim.		CONCORDO [0]			NÃO TENHO CERTEZA [0]	DISCORDO [1]
5.Eu não tomo meus remédios quando me sinto bem.		CONCORDO [0]			NÃO TENHO CERTEZA [0]	DISCORDO [1]
Pontuação da parte I (0–3): Pontuação da parte II (0–5): Total:

Edited by

• Associate Editor:
  Paula Hino (https://orcid.org/0000-0002-1408-196X) Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil

Data availability

The survey data are available in the article.

Publication Dates

• Publication in this collection
  20 Apr 2026
• Date of issue
  2026

History

• Received
  5 Feb 2025
• Accepted
  25 Aug 2025