Original Article
Translation and cultural adaptation of the Hill-Bone Compliance to High Blood Pressure Therapy Scale to Portuguese
Tradução e adaptação cultural do Questionário Hill-Bone de Adesão à Terapêutica Antihipertensora para Português
Luís Nogueira-Silvaa,b,
, Ana Sá-Sousab, Maria João Limaa, Agostinho Monteiroc, Cheryl Dennison-Himmelfarbd, João A. Fonsecab,e
Corresponding author
a Serviço de Medicina Interna, Centro Hospitalar S. João, Porto, Portugal
b CINTESIS – Centro de Investigação em Tecnologias e Sistemas de Informação em Saúde, Universidade do Porto, Portugal
c Faculdade de Medicina, Universidade do Porto, Portugal
d Johns Hopkins University School of Nursing, Baltimore, USA
e Unidade de Alergologia, Instituto CUF Porto e Hospital CUF Porto, Porto, Portugal
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"apellidos" => "Fonseca" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Serviço de Medicina Interna, Centro Hospitalar S. João, Porto, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "CINTESIS – Centro de Investigação em Tecnologias e Sistemas de Informação em Saúde, Universidade do Porto, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Faculdade de Medicina, Universidade do Porto, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Johns Hopkins University School of Nursing, Baltimore, USA" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Unidade de Alergologia, Instituto CUF Porto e Hospital CUF Porto, Porto, Portugal" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Tradução e adaptação cultural do Questionário <span class="elsevierStyleItalic">Hill-Bone</span> de Adesão à Terapêutica Antihipertensora para Português" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1780 "Ancho" => 2283 "Tamanyo" => 481518 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Original Hill-Bone Compliance to High Blood Pressure Therapy Scale.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Hypertension is a highly prevalent disease worldwide and is estimated to affect around 42% of Portuguese adults,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a> a prevalence that is predicted to grow in the future.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">2</span></a> Over the last decade, considerable improvements have been achieved in the care of hypertensive patients in Portugal, with the proportion of those receiving treatment increasing from less than 40%<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">3</span></a> to almost 75%; however, the proportion of controlled patients remains at an unsatisfactory 42.5%.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Poor adherence to therapy is an issue in all chronic diseases and even more important in a largely asymptomatic disease like hypertension.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">4</span></a> It leads to lack of control<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">5</span></a> and to a higher risk of cardiovascular events.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Several methods exist to assess adherence, which can be divided into direct and indirect approaches.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">7</span></a> Direct methods, such as directly observed therapy or measurement of drug metabolites in plasma or urine samples, are cumbersome or technically complex,<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">8,9</span></a> and are thus unavailable in daily practice. Indirect methods include electronic medication monitors, which are expensive and also largely unavailable outside the research environment,<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a> and questionnaires.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Adherence questionnaires have been developed, validated and used in patients with several chronic diseases.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">11,12</span></a> In hypertension, the most widely used questionnaire is the Morisky Medication Adherence Scale<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">13</span></a> but its Portuguese version is not free to use without a license from the author. Another commonly used questionnaire is the Hill-Bone Compliance to High Blood Pressure Therapy Scale, which has been developed and validated in a low literacy setting, and its psychometric characteristics described.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">14</span></a> A Portuguese version of this questionnaire does not exist.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Given the need to assess adherence to therapy with a simple and readily available instrument in daily practice, it was our aim to perform a translation and cultural adaptation of the Hill-Bone Compliance Scale from the original English to Portuguese.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">A formal translation and cultural adaptation process was performed, as recommended in the Principles of Good Practice of the International Society for Pharmacoeconomics and Outcomes Research regarding patient-reported outcomes (PRO) measures.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">15</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">As preparation, the authors of the original scale were contacted and provided authorization for the process; moreover, a member (CDH) of the team that developed and tested the original instrument was involved in the preparation of this manuscript. A working group was assembled, including physicians with experience in the care of hypertensive patients and physicians who have been responsible for the production, as well as translation and cultural adaptation, of questionnaires.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">16–18</span></a> Forward translation from English to European Portuguese was performed by two independent native Portuguese speakers who are fluent in English. Discrepancies were then discussed and resolved by consensus, involving the whole study group, producing a final forward translation version. Back translation was then performed by someone fluent in both languages who was neither involved in the previous steps nor familiar with the original scale. A more conceptual, rather than literal, style was employed in this step. The working group then compared the back translation against the original questionnaire in order to identify discrepancies in the concepts; if significant discrepancies were identified, the process of forward translation would be restarted.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Once no conceptual discrepancies were found between the original questionnaire and the Portuguese version, it was then presented to Portuguese-speaking hypertensive patients. Patients were recruited in the hypertension clinic of a University Hospital in Porto, Portugal. An effort was made to include patients with a variety of educational and cultural backgrounds. They were asked to fill the questionnaire paying particular attention to the construction and phrasing of the sentences, insuring that the concepts were interpreted appropriately. All patients’ difficulties or misunderstandings, as well as their opinions on the questionnaire, were analyzed and used as a basis for changes in the wording. This process was repeated until the questionnaire was understood correctly by the patients. The final version was reviewed by the working group and this report was prepared.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">The original version of the Hill-Bone Compliance Scale was obtained from the original authors (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>), as well as authorization to perform the translation process. Several discrepancies occurred, namely in the translation of the expression “shake salt on your food” in question 4, and the verbs “skip” and “miss taking” from questions 10 and 12–14. All differences were discussed and resolved, and a final forward translation version was produced by consensus (Supplement 1). The back translation was performed and, despite some wording differences, the resulting version showed no conceptual discrepancies with the original scale.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The Portuguese version was then presented to nine patients from the hypertension clinic. Numerous problems were identified, such as the expression ‘fast food’, which had been kept from the original and was not understood by most of the patients. The most important source of misunderstanding was the phrasing of questions 10, 11, 12 and 14 – patients tended to answer ‘All of the time’ (because they always took their medication) but the correct answer for that idea was ‘None of the time’. The translation into Portuguese of these questions implies a negative phrase and the desired answer ‘None of the time’ creates a double negative which was difficult for the patients. In addition, most patients had difficulties marking questions with a number that corresponds to a response option. In view of these findings, questions 10, 11 and 12 were changed to a positive phrasing, so that good adherence will produce a positive answer. Consequently, the score attributed to the response options for question 10 had to be changed, in order to preserve comparability with the scoring of the original scale. Furthermore, we changed the format of the questionnaire so that the response options are presented after the question (rather than a space to mark a number). This new version was presented to six other patients from the hypertension clinic. With the new version, no crucial difficulties or misunderstandings were detected. One patient had difficulty with question 2 (which also has a negative phrasing); we decided to maintain this phrasing and the capital letters for the negative particle, as in the original scale. Question 5 addresses the intake of food rich in salt; the available evidence shows that, in Portugal, most salt intake comes from salt-rich food, such as bread, cheese and sausages/cold meat.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">19</span></a> We therefore changed question 5 in order to include these examples. The final Portuguese version of the questionnaire (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>) was reviewed and accepted by the working group.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">We propose a Portuguese version of the Hill-Bone Compliance Scale, resulting from a formal translation and cultural adaptation process.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The development of PRO measures is crucial for the assessment of chronic diseases such as hypertension. Poor adherence to therapy is a major issue in hypertension care, but instruments that assess it are scarce. Despite multiple limitations, questionnaires are the most accessible instruments to assess adherence in daily clinical practice. PRO measures must be developed or translated to the language of the population that will use them. To our knowledge, no original European Portuguese adherence questionnaire or European Portuguese translations have been described in the literature.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The forward-backward translation process that we used is the most widely accepted method.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">15</span></a> Similar methods have been used for the translation of this questionnaire into other languages.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">20,21</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Several difficulties were identified after the first version was presented to patients. It was clear that the phrasing obtained by translation from the original English was too complex in the Portuguese language, especially for a questionnaire that is meant to be used by an elderly population with low literacy. The changes were clearly necessary for cultural adaptation.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The main strength of this study is the use of a formal methodology, which ensures that the version obtained maintains the same concepts as the original scale. Other concepts or domains that might be useful in the evaluation of adherence could not be included when following the standardized international recommendations for a translation and cultural adaptation process.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">15</span></a> The use of other questionnaires that analyze different dimensions may provide a broader assessment of adherence, namely of the reasons for non-adherence. A minor limitation is the fact that the study was conducted in a hospital clinic, while the questionnaire is intended also to be used in a primary care setting. However, the patients involved were of similar age, literacy level and socioeconomic background to most hypertensive patients in primary care, had mostly essential, not resistant, hypertension, and were originally referred to the hospital by primary care physicians. Furthermore, we do not describe a validation process, and the psychometric characteristics of the Portuguese Hill-Bone Compliance Scale should be evaluated in the future.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusion</span><p id="par0080" class="elsevierStylePara elsevierViewall">We describe the translation and cultural adaptation of the Hill-Bone Compliance Scale and propose a European Portuguese version to be used with hypertensive patients in a primary or hospital setting. Further studies are necessary for the validation of this new version.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical disclosures</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Protection of human and animal subjects</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Confidentiality of data</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appears in this article.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Right to privacy and informed consent</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appears in this article.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres818333" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec815362" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres818332" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introdução" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec815363" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 9 => array:3 [ "identificador" => "sec0030" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of interest" ] 11 => array:2 [ "identificador" => "xack274596" "titulo" => "Acknowledgments" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-03-19" "fechaAceptado" => "2015-07-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec815362" "palabras" => array:5 [ 0 => "Hypertension" 1 => "Medication adherence" 2 => "Questionnaires" 3 => "Translation and cultural adaptation" 4 => "Patient-reported outcomes" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec815363" "palabras" => array:5 [ 0 => "Hipertensão arterial" 1 => "Adesão à terapêutica" 2 => "Questionários" 3 => "Tradução e adaptação cultural" 4 => "<span class="elsevierStyleItalic">Patient-reported outcomes</span>" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hypertension is an extremely prevalent disease worldwide and hypertension control rates remain low. Lack of adherence contributes to poor control and to cardiovascular events. No questionnaire in Portuguese is readily available for the assessment of adherence to antihypertensive drugs. We aimed to perform a translation and cultural adaptation to Portuguese of the Hill-Bone Compliance to High Blood Pressure Therapy Scale, a validated instrument to measure adherence in hypertensive patients.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A formal process was employed, consisting of a forward translation by two independent translators and a back translation by a third translator. Discrepancies were resolved after each step. Hypertensive patients were involved to identify and resolve phrasing and wording difficulties and misunderstandings.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The forward and back translation did not produce significant discrepancies. However, important issues were identified when the questionnaire was presented to patients, which led to changes in the wording of the questions and in the format of the questionnaire.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Questionnaires are important instruments to assess adherence to therapy, particularly in hypertension. A formal translation and cultural adaptation process ensures that the new version maintains the same concepts as the original. After translation, several changes were necessary to ensure that the questionnaire was understandable by elderly, low literacy patients, such as the majority of hypertensive patients. We propose a Portuguese version of the Hill-Bone Compliance Scale, which will require validation in further studies.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introdução</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A hipertensão arterial (HTA) é extremamente prevalente em todo o mundo e a proporção de doentes controlados permanece baixa. A má adesão à terapêutica dificulta o controlo da doença e contribui para a ocorrência de eventos cardiovasculares. Não existe nenhum questionário em português imediatamente disponível para avaliar a adesão a fármacos anti-hipertensores. O nosso objetivo é realizar a tradução e adaptação cultural do questionário de adesão <span class="elsevierStyleItalic">Hill-Bone</span>, um instrumento validado em doentes com HTA.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Foi utilizado um processo formal, consistindo numa tradução para português por dois tradutores, seguida de uma retroversão para inglês por um terceiro tradutor. As discrepâncias foram discutidas e resolvidas após cada passo. Doentes com HTA foram envolvidos, de forma a identificar e corrigir construções de frases e escolhas de palavras que provocaram problemas de compreensão.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A tradução e retroversão não produziram discrepâncias relevantes. Foram identificados problemas de compreensão importantes quando o questionário foi apresentado aos doentes, motivando alterações na elaboração das perguntas e no formato do questionário.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusão</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Os questionários são instrumentos importantes na avaliação da adesão à terapêutica, em particular na HTA. O processo formal de tradução e adaptação cultural visa garantir que a nova versão mantém os mesmos conceitos que o original. Várias alterações foram necessárias para garantir que o questionário é corretamente interpretado por indivíduos idosos e com baixa literacia, características de grande parte dos doentes hipertensos. Propomos a versão portuguesa do questionário <span class="elsevierStyleItalic">Hill-Bone</span> de adesão à terapêutica anti-hipertensora, que deverá ser validada em estudos futuros.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introdução" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0115" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary material" "identificador" => "sec0060" ] ] ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1780 "Ancho" => 2283 "Tamanyo" => 481518 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Original Hill-Bone Compliance to High Blood Pressure Therapy Scale.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2243 "Ancho" => 3376 "Tamanyo" => 740345 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Final Portuguese version of the Hill-Bone Compliance to High Blood Pressure Therapy Scale.</p>" ] ] 2 => array:7 [ "identificador" => "upi0005" "etiqueta" => "Supplement 1" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.doc" "ficheroTamanyo" => 1016832 ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">First Portuguese version of the Hill-Bone Compliance to High Blood Pressure Therapy Scale, which presented several difficulties for patients.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:21 [ 0 => array:3 [ "identificador" => "bib0110" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence, awareness, treatment and control of hypertension and salt intake in Portugal: changes over a decade. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 3 | 12 |
| 2024 October | 87 | 46 | 133 |
| 2024 September | 105 | 22 | 127 |
| 2024 August | 77 | 26 | 103 |
| 2024 July | 63 | 33 | 96 |
| 2024 June | 48 | 24 | 72 |
| 2024 May | 57 | 28 | 85 |
| 2024 April | 66 | 30 | 96 |
| 2024 March | 94 | 27 | 121 |
| 2024 February | 95 | 23 | 118 |
| 2024 January | 61 | 30 | 91 |
| 2023 December | 40 | 40 | 80 |
| 2023 November | 64 | 40 | 104 |
| 2023 October | 49 | 22 | 71 |
| 2023 September | 40 | 26 | 66 |
| 2023 August | 52 | 23 | 75 |
| 2023 July | 69 | 21 | 90 |
| 2023 June | 56 | 13 | 69 |
| 2023 May | 73 | 29 | 102 |
| 2023 April | 51 | 8 | 59 |
| 2023 March | 85 | 27 | 112 |
| 2023 February | 106 | 29 | 135 |
| 2023 January | 76 | 23 | 99 |
| 2022 December | 79 | 24 | 103 |
| 2022 November | 84 | 31 | 115 |
| 2022 October | 103 | 17 | 120 |
| 2022 September | 86 | 42 | 128 |
| 2022 August | 105 | 59 | 164 |
| 2022 July | 103 | 72 | 175 |
| 2022 June | 65 | 32 | 97 |
| 2022 May | 93 | 41 | 134 |
| 2022 April | 101 | 33 | 134 |
| 2022 March | 71 | 33 | 104 |
| 2022 February | 116 | 18 | 134 |
| 2022 January | 198 | 29 | 227 |
| 2021 December | 126 | 37 | 163 |
| 2021 November | 92 | 45 | 137 |
| 2021 October | 168 | 49 | 217 |
| 2021 September | 107 | 41 | 148 |
| 2021 August | 141 | 66 | 207 |
| 2021 July | 181 | 30 | 211 |
| 2021 June | 102 | 34 | 136 |
| 2021 May | 77 | 40 | 117 |
| 2021 April | 186 | 27 | 213 |
| 2021 March | 151 | 27 | 178 |
| 2021 February | 114 | 14 | 128 |
| 2021 January | 69 | 18 | 87 |
| 2020 December | 46 | 13 | 59 |
| 2020 November | 75 | 12 | 87 |
| 2020 October | 97 | 18 | 115 |
| 2020 September | 88 | 16 | 104 |
| 2020 August | 67 | 10 | 77 |
| 2020 July | 71 | 21 | 92 |
| 2020 June | 82 | 24 | 106 |
| 2020 May | 102 | 16 | 118 |
| 2020 April | 82 | 31 | 113 |
| 2020 March | 65 | 10 | 75 |
| 2020 February | 205 | 28 | 233 |
| 2020 January | 66 | 11 | 77 |
| 2019 December | 101 | 9 | 110 |
| 2019 November | 65 | 14 | 79 |
| 2019 October | 57 | 9 | 66 |
| 2019 September | 79 | 15 | 94 |
| 2019 August | 37 | 6 | 43 |
| 2019 July | 40 | 7 | 47 |
| 2019 June | 51 | 10 | 61 |
| 2019 May | 52 | 7 | 59 |
| 2019 April | 60 | 29 | 89 |
| 2019 March | 106 | 15 | 121 |
| 2019 February | 91 | 10 | 101 |
| 2019 January | 80 | 16 | 96 |
| 2018 December | 87 | 12 | 99 |
| 2018 November | 180 | 9 | 189 |
| 2018 October | 390 | 37 | 427 |
| 2018 September | 159 | 27 | 186 |
| 2018 August | 161 | 22 | 183 |
| 2018 July | 100 | 7 | 107 |
| 2018 June | 89 | 9 | 98 |
| 2018 May | 97 | 6 | 103 |
| 2018 April | 99 | 13 | 112 |
| 2018 March | 113 | 9 | 122 |
| 2018 February | 89 | 23 | 112 |
| 2018 January | 99 | 10 | 109 |
| 2017 December | 138 | 7 | 145 |
| 2017 November | 56 | 14 | 70 |
| 2017 October | 41 | 10 | 51 |
| 2017 September | 53 | 14 | 67 |
| 2017 August | 40 | 13 | 53 |
| 2017 July | 32 | 6 | 38 |
| 2017 June | 43 | 10 | 53 |
| 2017 May | 49 | 25 | 74 |
| 2017 April | 32 | 6 | 38 |
| 2017 March | 59 | 7 | 66 |
| 2017 February | 50 | 10 | 60 |
| 2017 January | 49 | 3 | 52 |
| 2016 December | 53 | 7 | 60 |
| 2016 November | 48 | 5 | 53 |
| 2016 October | 73 | 9 | 82 |
| 2016 September | 80 | 6 | 86 |
| 2016 August | 42 | 9 | 51 |
| 2016 July | 32 | 6 | 38 |
| 2016 June | 24 | 1 | 25 |
| 2016 May | 31 | 8 | 39 |
| 2016 April | 32 | 1 | 33 |
| 2016 March | 66 | 34 | 100 |
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