ijcs International Journal of Cardiovascular Sciences Int J Cardiovasc Sci 2359-4802 2359-5647 Sociedade Brasileira de Cardiologia 9rJVLpJLfNFJXh6QCsBBgVv S2359-56472023000100256 00256 10.36660/ijcs.20230075 ORIGINAL ARTICLE Translation, Cross-Cultural Adaptation, and Validation of the Hypertension Self-Care Profile (HBP-SCP) for the Brazilian Population 0000-0003-2508-1364 Baggio Jussara Almeida de Oliveira Conception and design of the research acquisition of data analysis and interpretation of the data statistical analysis writing of the manuscript critical revision of the manuscript for intellectual content 1 Ribeiro Beatriz Brito acquisition of data analysis and interpretation of the data; writing of the manuscript 1 Ribeiro Jessica Lays Ferreira acquisition of data analysis and interpretation of the data writing of the manuscript 1 Silva Fabricio Brito analysis and interpretation of the data critical revision of the manuscript for intellectual content 2 0000-0002-5234-015X Azevedo Lisiane Fernanda Simeão de Conception and design of the research analysis and interpretation of the data critical revision of the manuscript for intellectual content 2 Mendes Renata Gonçalves Conception and design of the research analysis and interpretation of the data critical revision of the manuscript for intellectual content 3 0000-0001-6436-9059 Araújo Aldair Darlan Conception and design of the research acquisition of data analysis and interpretation of the data critical revision of the manuscript for intellectual content 3 Gonçalves Maria Claudia Conception and design of the research analysis and interpretation of the data critical revision of the manuscript for intellectual content 2 0000-0002-3525-9245 Tavarez Rudys Rodolfo de Jesus Conception and design of the research analysis and interpretation of the data critical revision of the manuscript for intellectual content 4 Almeida Denilson Menezes analysis and interpretation of the data critical revision of the manuscript for intellectual content 5 0000-0002-6140-0177 Bassi-Dibai Daniela Conception and design of the research analysis and interpretation of the data statistical analysis; critical revision of the manuscript for intellectual content 5 Medical school Federal University of Alagoas Arapiraca Alagoas Brazil Medical school of Federal University of Alagoas, Arapiraca, Alagoas – Brazil Postgraduate Program in Environment Universidade Ceuma São Luís Maranhão Brazil Postgraduate Program in Environment, Universidade Ceuma, São Luís, Maranhão – Brazil Postgraduate Program in Physical Therapy Universidade Federal de São Carlos São Carlos São Paulo Brazil Postgraduate Program in Physical Therapy, Universidade Federal de São Carlos, São Carlos, São Paulo – Brazil Postgraduate Program in Odontology Universidade Ceuma São Luís Maranhão Brazil Postgraduate Program in Odontology, Universidade Ceuma, São Luís, Maranhão – Brazil Postgraduate Program in Management of Health Programs and Services Universidade Ceuma São Luís Maranhão Brazil Postgraduate Program in Management of Health Programs and Services, Universidade Ceuma, São Luís, Maranhão – Brazil Mailing Address: Jussara Almeida de Oliveira Baggio Universidade Federal de Alagoas, Campus Arapiraca, Curso de Medicina. Avenida Empresário Carlos da Silva Nogueira, 16. Postal code: 57036-540. Maceió, AL – Brazil. E-mail: jussarabaggio@gmail.com

Potential Conflict of Interest

No potential conflict of interest relevant to this article was reported.

 22 12 2023 2023 36 e20230075 24 05 2023 26 06 2023 20 09 2023 This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

: Translation, Cross-Cultural Adaptation, and Validation of the Hypertension Self-Care Profile (HBP-SCP) for the Brazilian Population

Abstract Background

Self-care in the management of systemic arterial hypertension (SAH) is crucial, and validated instruments can help researchers and health professionals to plan strategies to improve self-care in people with SAH.

 Objective

The main objective of this study was to translate, cross-culturally adapt, and validated the Hypertension Self-Care Profile (HBP-SCP) for Brazilian Portuguese.

 Methods

The translation and cross-cultural adaptation was performed in five phases, and the pre-final version was tested in 30 individuals, native speakers of Portuguese with a diagnosis of hypertension. The final version was administered in 100 individuals. The inclusion criteria were: diagnosis of SAH, characterized by systolic arterial blood pressure ≥ 140 mmHg and/or diastolic arterial blood pressure ≥ 90mmHg, regular use of antihypertensive medications and over 18 years of age. The present study also used two other questionnaires, previously validated for the Brazilian population, to verify the validity of the construct, the Healthy Habits Perception Questionnaire (HHPQ) and the Quality of Life in Hypertension Mini-Questionnaire (MINICHAL-BRASIL).

 Results

During the translation and cross-cultural adaptation phase, there were no disagreements. Adequate reliability — intraclass correlation coefficient (ICC) ≥ 0.89, standard error of measurement (SEM) % ≤ 4.34, minimum detectable change (MDC) % ≤ 12.04 — and internal consistency (Cronbach's alpha ≥ 0.75) were observed. The behavior domain of HBP-SCP obtained significant correlations (p < 0.05) with the self-efficacy domain and HHPQ; the motivation domain with the self-efficacy domain; and the self-efficacy domain with the somatic manifestation domain of MINICHAL-BRASIL. No ceiling and floor effects were observed.

 Conclusions

The Brazilian Portuguese version of the HBP-SCP has adequate psychometric properties, according to the best scientific recommendations.

 Self-Care Hypertension Validation Study Introduction

Systemic arterial hypertension (SAH) is highly prevalent worldwide. In Brazil, according to the latest National Health Survey (NHS), there are more than 38 million people living with SAH,1 and the prevalence is higher in women, older people, people with a low educational level, and people living in the South and Southeast of Brazil.2

SAH treatment is multifactorial and involves antihypertensive medications and changes in lifestyle.3 The adherence of healthy habits among Brazilian people with the diagnosis of SAH increased in recent years; however, the level of sedentary lifestyle and the consumption of ultra-processed food is still very high.4 Self-care in the management of SAH is crucial, and validated instruments can help researchers and health professionals to plan strategies to improve self-care in people with SAH.

The majority of the instruments available to evaluate self-care in people with SAH have not been rigorously evaluated and do not access all domains related to self-care.5 For this reason, the Hypertension Self-Care Profile (HBP-SCP) was developed to cover the following areas: the intake of medication, physical activity, low-sodium and low-fat diet, restrictions of alcohol consumption, non-smoker, self-monitoring of blood pressure, weight control, regular doctor visits, and stress reduction.6 The HBP-SCP also proved to be sensitive in detecting differences among people with and without adequate blood pressure control and showed a good concurrent validity.

The main objective of this study was to translate, cross-culturally adapt, and validated the HBP-SCP for Brazilian Portuguese.

 Methods Study design and ethics

This was a cross-sectional study on the translation, cross-cultural adaptation, and validation of a questionnaire. The original authors gave their authorization by e-mail for psychometric analysis. This study was conducted in accordance with the Guidelines for the Process of Cross-Cultural Adaptation of Self-Reported Measures 7 and the Consensus-based Standards for the selection of health measurement instruments (COSMIN).8

This study was approved by the Research Ethics Committee from Ceuma University, logged under protocol number 96301118.0.0000.5084, and all participants validated their participation by signing a free and informed consent form.

HBP-SCP Translation and cross-cultural adaptation

The translation and cross-cultural adaptation follow the criteria of Beaton et al.7 and were performed in five stages: (1) The translation was made by two independent translators, both were Brazilians and fluent in English; (2) The two translated versions were then compared and adapted to reach a final consensual version; (3) Two independent translators, both English native speakers and fluent in Portuguese, translated the Portuguese version of the questionnaire back to English, with no previous knowledge of the original version of the questionnaire; (4) An expert committee reviewed the original, translated, synthetized, and back-translated versions of the questionnaire, and then defined the pre-final version of the HBP-SCP, and (5) finally, the pre-final version was administered to 30 individuals, native speakers of Portuguese with a diagnosis of hypertension. The respondents’ comprehension of the items and responses in the HBP-SCP was evaluated.

 Participants

The sample size for this validation study was based on COSMIN, and a minimum of 100 individuals was recommended.8 The inclusion criteria were: diagnosis of SAH, characterized by systolic arterial blood pressure ≥ 140 mmHg and/or diastolic arterial blood pressure ≥ 90mmHg,3 the regular use of antihypertensive medications, and being over 18 years of age. Subjects with cognitive impairment, communication problems, or hearing loss with no correction were excluded from the study.

 HBP-SCP

The HBP-SCP was developed by Han et al.6 and measures the perception of patients with SAH concerning the recommendation of self-care. The consists of 60 items divided into three subscales: Behavior, Motivation, and Self-Efficacy. In these subscales, the instructions change from “How often do you do the following?” to “How important is it for you to do the following?” and “How confident are you that you could do the following?”, respectively. The score for each subscale is 80 points, with a total of 240. Higher scores indicate higher levels of self-care behavior, motivation, and self-efficacy.

 Other questionnaires

Two other questionnaires, which had been previously validated for the Brazilian population in order to verify the validity of the construct, were used. The Healthy Habits Perception Questionnaire (HHPQ) was developed for teenagers to measure their perception of weight control, consumption of healthy foods, and regular practice of physical exercise. The questionnaire contains 30 items and higher scores indicate a better perception of healthy habits.9

The Quality of Life in Hypertension Mini-Questionnaire (MINICHAL-BRASIL) was validated by Schulz et al.10 This questionnaire contains 16 multiple-choice questions organized into two factors – Mental status (10 questions) and Somatic manifestations (6 questions) – together with a final question to verify how the patient evaluates the way that hypertension and its treatment have influenced their quality of life. Lower scores indicate a better quality of life.

 Statistical analysis

Reliability was assessed based on a test-retest model by measuring the intraclass correlation coefficient (ICC), standard error of measurement (SEM) and minimum detectable change (MDC). The ICC values were interpreted based on the study by Fleiss: for values below 0.40, reliability was considered low; between 0.40 and 0.75, moderate; between 0.75 and 0.90, substantial; and greater than 0.90, excellent.11 The SEM percentage was interpreted based on the definitions of Ostelo et al.: 5% or less, very good; greater than 5% and less than or equal to 10%, good; greater than 10% and less than or equal to 20%, doubtful; and greater than 20%, negative.12 Internal consistency was assessed using Cronbach’s alpha (values above 0.70 were considered adequate).13

To ascertain the validity of the construct, Spearman's correlation coefficient (rs) was used to determine the magnitude of the correlations between the HBP-SCP and the HHPQ, and between the HBP-SCP and the MINICHAL-BRASIL. The rs values were interpreted in accordance with the COSMIN recommendations: correlations with instruments measuring similar constructs should be ≥ 0.50; correlations with instruments measuring related but dissimilar constructs should be 0.30-0.50; and correlations with instruments measuring unrelated constructs should be < 0.30.8 We expect correlations > 0.50 between the HBP-SCP domains and < 0.30 with the MINICHAL-BRASIL and HHPQ.

Ceiling and floor effects were evaluated in the present study. By definition, these effects occurred when a number of study participants (set as over 15%) reached the minimum or maximum values of the total score of the questionnaire.

 Results

During the translation and cross-cultural adaptation phase, there were no disagreements or suggestions for changes to the questionnaire. The translated and adapted version of the HBP-SCP was unanimously established by the expert committee. Therefore, this version was then applied to 30 patients with hypertension to assess the level of understanding of the questions. We observed 100% comprehension for all items in the questionnaire. Thus, the final Brazilian Portuguese version of the HBP-SCP was defined.

One hundred participants with hypertension were recruited and included in the study. The data were collected in the cities of Arapiraca, AL, Brazil, and São Luís, MA, Brazil. From this total sample, a sub-sample with 30 participants was used for the test-retest reliability calculations. Table 1 presents the characteristics of the sample, and it was observed that most of the participants were women (74%), married (67%), who were overweight (body mass index: 29.25kg/m2), and with more than 9 years of SAH.

– Sociodemographic and clinical characteristics of the participants.
Characteristics Reliability phase (n = 30) Validity phase (n = 100)
Age (years) 57.23 (10.85) 63.46 (11.50)
Gender (female) 24 (80%) 74 (74%)
Marital status
Single 11 (36.7%) 10 (10%)
Married 16 (53.3%) 67 (67%)
Divorced 0 (0%) 8 (8%)
Widower 3 (10%) 15 (15%)
Weight (kg) 75.05 (16.63) 72.82 (16.97)
Height (m) 1.57 (0.05) 1.57 (0.09)
BMI (kg/m2) 29.87 (5.44) 29.25 (5.88)
Abdominal circumference (cm) 98.30 (9.57) 97.85 (13.84)
Schooling
Basic education 25 (83.4%) 75 (75%)
High school 4 (13.3%) 11 (11%)
Higher education 1 (3.3%) 14 (14%)
Chronicity of SAH (years) 10.40 (10.17) 9.48 (8.28)
PAS (mmHg) 132.50 (10.40) 128.76 (13.35)
PAD (mmHg) 92.33 (13.56) 75.15 (18.90)
Physical activity (yes) 6 (20%) 33 (33%)
HHPQ (score) 80.16 (8.51) 84.97 (10.43)
MINICHAL-BRASIL (score)
Mental state 6.33 (5.04) 6.43 (4.81)
Somatic manifestations 5.20 (2.59) 5.76 (3.84)
HBP-SCP (score)
Behavior 49.36 (8.21) 52.96 (9.36)
Motivation 72.26 (8.21) 64.25 (5.02)
Self-efficacy 66.30 (8.90) 61.86 (5.24)

Values presented in mean (standard deviation, SD) or number (percentage). BMI: body mass index; SAH: systemic arterial hypertension; HBP-SCP: Hypertension Self-Care Profile; HHPQ: Healthy Habits Perception Questionnaire; MINICHAL-BRASIL: Quality of Life in Hypertension Mini-Questionnaire; PAS: systolic blood pressure; PAD: diastolic blood pressure.

Regarding reliability (Table 2), considering the total score of each domain, we observed adequate reliability (ICC ≥ 0.89, SEM% ≤ 4.34, MDC% ≤ 12.04) and internal consistency (Cronbach's alpha ≥ 0.75).

– Reliability of the HBP-SCP domains with presentation of mean values, standard deviation (SD), ICC and 95% confidence interval (CI), SEM, MDC, and Cronbach's alpha.
HBP-SCP Test Retest ICC (95% CI) SEM (absolute) SEM (%) MDC (absolute) MDC (%) Cronbach’s alpha
Behavior 49.36 (8.21) 51.43 (8.34) 0.93 (0.85, 0.96) 2.19 4.34 6.07 12.04 0.75
Motivation 72.26 (8.21) 72.36 (6.72) 0.90 (0.79, 0.95) 2.36 3.26 6.54 9.05 0.78
Self-efficacy 66.30 (8.90) 65.83 (5.60) 0.89 (0.77, 0.95) 2.40 3.64 6.67 10.09 0.78

HBP-SCP: Hypertension Self-Care Profile; ICC: intraclass correlation coefficient; SEM: standard error of measurement; MDC: minimum detectable change.

To assess the construct validity by means of correlation with a validated questionnaire (Table 3), the following significant (p < 0.05) correlations were observed: behavior domain with self-efficacy domain and HHPQ; motivation domain with self-efficacy domain; self-efficacy domain with somatic manifestations domain of MINICHAL, in addition to the two other HBP-SCP domains mentioned above.

– Correlation between the HBP-SCP domains and the other questionnaires applied in the study sample (n = 100).
Questionnaires HBP-SCP
Behavior Motivation Self-efficacy
HBP-SCP
Behavior rs = 1.000 - -
Motivation rs = 0.120, p = 0.236 rs = 1.000 -
Self-efficacy rs = 0.354, p = 0.001 * rs = 0.728, p = 0.001 * rs = 1.000
HHPQ rs = 0.230, p = 0.021 * rs = 0.078, p = 0.441 rs = 0.099, p = 0.329
MINICHAL-BRASIL
Mental state rs = -0.067, p = 0.508 rs = -0.026, p = 0.794 rs = -0.120, p = 0.235
Somatic manifestations rs = -0.139, p = 0.168 rs = -0.138, p = 0.172 rs = -0.211, p = 0.035 *

HHPQ: Healthy Habits Perception Questionnaire; MINICHAL-BRASIL: Quality of Life in Hypertension Mini-Questionnaire; HBP-SCP: Hypertension Self-Care Profile. * Statistically significant correlation (p <0.05, Spearman's correlation coefficient).

No participants achieved a maximum or minimum score of the HBP-SCP domains. Therefore, ceiling and floor effects were not observed.

 Discussion

The Brazilian Portuguese version of HBP-SCP showed a good level of comprehension among participants, with a 100% comprehension in all items of the questionnaire. The HBP-SCP also showed acceptable values of reliability (ICC ≥ 0.89) and internal consistency (Cronbach's alpha ≥ 0.75). To access construct validity, the HBP-SCP was correlated with HHPQ and MINICHAL-BRASIL, and significant correlations were observed.

The HBP-SCP has already been validated to others languages, and all showed acceptable reliability and validity. The Turkish version14 and the Chinese version15 obtained higher values of internal consistency when compared to the Brazilian version. The Turkish version found a Cronbach's alpha of 0.93 for the HBP-SCP-Behavior scale and Motivation scale, and 0.94 for the Self-efficacy scale, while the Chinese version found values of 0.86, 0.94 and 0.93, respectively. However, the literature defines values > 0.70 as adequate for internal consistency,13 thus showing that the Brazilian version also had an adequate internal consistency.

The ICC values of the Brazilian version of HBP-SCP were higher (ICC 0.93, 0.90, 0.89) when compared to the Turkish14 (ICC = 0.75, 0.75, 0.76), Mandarin16 (0.64, 0.57, 0.71), and Malay versions17 (0.66, 0.65, 0.68). The Mandarin and Malay versions16,17 used a web-based approach to access the test-retest. The participants filled out the HBP-SCP in a web-based online tool and, after 2 weeks, were instructed to do the retest, using their own electronic devices. The use of remote assessment is widely used; however, depending on the context and population, caution is necessary. In Brazil, a considerable portion of the population does not have access to the internet and has a low educational level. Similar to our study, the Turkish version used a face-to-face interview and found better results in ICC.14

The ideal management of SAH involves pharmacological and non-pharmacological treatment. The latter is based on changes in lifestyle related to reduction in salt intake, the regular practice of physical exercise, an adequate consumption of healthy foods, and weight loss. The success of these measures depends on the correct understanding and adherence of the patient. For this reason, self-care measures can help the health professional to access and improve treatment adherence.

 Conclusion

The Brazilian Portuguese version of the HBP-SCP has adequate psychometric properties according to the best scientific recommendations.

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Sources of Funding: There were no external funding sources for this study.