The idea for this study was not born in a planning meeting or from a statistical anomaly, it came from a conversation. One of those field moments that unsettles you long after the day’s work is over. We were collecting qualitative data for another TB-related study when we met an elderly man recently diagnosed with tuberculosis. He had started the standard treatment regimen, including rifampicin, a core anti-TB drug known for turning urine a bright orange-red. Health workers had thoroughly explained this to him at the time of diagnosis. The change in urine color was expected, they said. Nothing to worry about. A sign the medicine was doing its job.

But within a few days, he stopped his medication.

When the team visited to check in, he told them he was frightened, his urine had turned orange, and in his words, “I was fine before the medicine. Now I’m sick.” He was not being defiant. He was afraid. And no matter how carefully the health staff reiterated the message about rifampicin, about harmless side effects, he simply did not believe it. His wife, also undergoing TB treatment, had quietly stopped hers too. A physician visited. So did a TB program officer. Each tried to reassure him, to build trust. But the man remained unconvinced. He saw the medicine as the source of his illness, not the cure.

What shifted the story was unexpected. A seasoned frontline health worker, after repeated failed attempts, asked the couple’s daughter to speak with them. She sat beside her father, spoke gently, and told him that she wanted him to live. That he had to trust the medicine, for her. And somehow, through that familiar voice, the message landed. It wasn’t the information that changed it was the messenger, the relationship, the trust. The couple resumed treatment.

That moment stayed with us not just for its emotional impact, but because it exposed a gap we hadn’t fully grasped before. The health system had done what it was supposed to: deliver accurate information, early and clearly. But something still broke down. It wasn’t a failure of knowledge transmission, strictly speaking, it was a failure of comprehension, belief, and alignment. We began to think deeply about what had worked in that interaction. Why did the daughter succeed where trained professionals could not? What allowed her words to be heard and accepted? That’s when the concept of health literacy moved from theory to urgency for us.

Health literacy is often spoken about in broad terms recognized as important, yet seldom examined through the lived experiences of patients.. But in that moment, it was everything. Not just the patient’s own ability to understand the medicine, but the role of his daughter in translating information into meaning. The more we thought about it, the more we recognized that TB care often assumes a linear model: diagnosis, counselling, adherence. But real life is rarely linear. Beliefs, fears, side effects, and social dynamics all shape how treatment unfolds. That experience made us ask: How health literate are TB patients, really? Especially those with multiple conditions? And can we begin to measure this in a way that offers actionable insight?

Our study, recently published in Discover Public Health, set out to assess health literacy among individuals with tuberculosis in India, including those with TB multimorbidity. TB patients are not a monolith. Some are managing diabetes, others HIV or other chronic illnesses. These intersections complicate health information, introduce multiple care providers, and demand far greater agency from patients navigating the health system. We used a structured tool to assess both functional and critical health literacy. Not just whether people could read health materials, but whether they could apply what they learned, ask questions, and make decisions.

The results were sobering. A significant proportion of participants demonstrated low health literacy, and this was more pronounced among patients with TB multimorbidity. This raises uncomfortable but necessary questions for TB programs. Are we measuring the right things when we assess program success? Are we assuming comprehension when we see compliance? And most importantly, are we equipping patients not just with pills and appointments, but with the clarity and confidence to navigate their treatment?

The man who refused rifampicin wasn’t resistant, he was confused, frightened, and overwhelmed. The health system gave him a medicine. His daughter gave him understanding. While our study focuses on individual health literacy, our fieldwork constantly reminded us of the social dimension what some scholars call distributed health literacy. A patient’s ability to make informed choices is not just about their own capacity, but also the people they trust, the language they speak at home, the cultural frames they live within.

We don’t claim to have all the answers. But we believe health literacy must be treated as foundational to TB care, especially as India moves toward ambitious TB elimination goals. Our study is a first step a mapping of where patients stand. The next steps are equally urgent: tailoring communication strategies, supporting caregivers, equipping frontline workers not just to inform, but to ensure understanding. Because ultimately, TB elimination is not just a biomedical challenge, it’s a human one.