ABC | Volume 110, Nº1, January 2018

Original Article Santos et al Development and psychometric validation of HIPER-Q Arq Bras Cardiol. 2018; 110(1):60-67 Table 4 – Classification of the HIPER-Q factorial structure by loadings Item Domain Factors 1 2 3 4 5 17 Self-care 0.825 6 Treatment 0.792 5 Diagnosis 0.745 11 Physical exercise 0.664 1 Concept and pathophysiology 0.477 14 Treatment 0.646 13 Concept and pathophysiology 0.631 3 Signs and symptoms 0.525 16 Diagnostic 0.734 4 Physical exercise 0.63 8 Physical exercise 0.635 7 Risk factors 0.534 12 Risk factors 0.470 2 Risk factors 0.328 10 Physical exercise 0.684 9 Self-care 0.580 15 Self-care 0.426 about SAH. These findings suggest that socioeconomical factors are determinants of knowledge about health, as previously demonstrated. 12,22,31,33 The current study also evaluated the level of knowledge of the sample patients, who showed an overall knowledge classified as “acceptable”. Our findings, supported by other authors, 13,18-21 reflect the importance of evaluating the knowledge about health and formulating hypothesis that elucidate the determining factors of the information gaps. Therefore, patient education is an important component of CR programs 9,28 and is associated with a successful self‑management of disease and patient’s behavior changes. 33 We did not find in the literature, longitudinal studies demonstrating the effects of a higher level of knowledge about SAH on outcomes, such as worse prognosis or mortality. Thus, one may expect that the HIPER-Q can be used in this regard in future studies. In this context, studies on other chronic diseases have shown promising results, suggesting that disease‑related education may be determinant in the control of risk factors, such as sedentary lifestyle, smoking and continuity of treatment, which may lead to reductions in comorbidities, health costs and even mortality. 34,35 In this scenario, there is a lack of instruments to measure the knowledge about the disease in participants of CR. 31 Most of the studies reviewed have only developed SAH questions deemed as relevant by the authors, 13,14,20-23 without conducting a psychometric validation as performed in the present study. 25,36 In addition, other validated studies have not specifically evaluated the knowledge of hypertensive patients in CR. 16-19,37-39 Therefore, our study aimed to develop an instrument to healthcare professionals, capable of establishing educational strategies directed to patients’ needs, 12,31 and that would help in the evaluation and planning of the educational process of hypertensive subjects in CR programs. Caution is needed in interpreting these findings. First, the results cannot be generalized, due to the facts that the sample was selected by convenience, and only three CR programs were included, which affects the achievement of the outcomes. Second, the development of the instrument proposed was based on consensus and guidelines, which encompass numerous SAH-related issues not necessarily covered by CR programs. Third, although all patients included were participants of CR programs, the programs were different (of public and private nature), with different approaches, which may have influenced the results. Fourth, the instrument was not developed using plain language techniques, or “simple” language, which may have created difficulties in the interpretation of the items, and consequently affected the results. 36 Fifth, the current study did not achieve the sample size recommended by the test-retest procedure. 36 Sixth, participants were not asked about their occupations, which may also have influenced the results, since patients graduated in medicine and/or other health-related areas, for example, may have had greater chance of giving correct answers. Further studies are needed to evaluate whether the HIPER-Q is sensitive to longitudinal changes by assessing patients’ knowledge before and after their participation in CR programs. 65