{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,25]],"date-time":"2026-04-25T12:16:37Z","timestamp":1777119397298,"version":"3.51.4"},"reference-count":55,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2021,5,3]],"date-time":"2021-05-03T00:00:00Z","timestamp":1620000000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Medication adherence is a priority for health systems worldwide and is widely recognised as a key component of quality of care for disease management. Adherence-related indicators were rarely explicitly included in national health policy agendas. One barrier is the lack of standardised adherence terminology and of routine measures of adherence in clinical practice. This paper discusses the possibility of developing adherence-related performance indicators highlighting the value of measuring persistence as a robust indicator of quality of care. To standardise adherence and persistence-related terminology allowing for benchmarking of adherence strategies, the European Ascertaining Barriers for Compliance (ABC) project proposed a Taxonomy of Adherence in 2012 consisting of three components: initiation, implementation, discontinuation. Persistence, which immediately precedes discontinuation, is a key element of taxonomy, which could capture adherence chronology allowing the examination of patterns of medication-taking behaviour. Advances in eHealth and Information Communication Technology (ICT) could play a major role in providing necessary structures to develop persistence indicators. We propose measuring persistence as an informative and pragmatic measure of medication-taking behaviour. Our view is to develop quality and performance indicators of persistence, which requires investing in ICT solutions enabling healthcare providers to review complete information on patients\u2019 medication-taking patterns, as well as clinical and health outcomes.<\/jats:p>","DOI":"10.3390\/ijerph18094872","type":"journal-article","created":{"date-parts":[[2021,5,5]],"date-time":"2021-05-05T11:06:01Z","timestamp":1620212761000},"page":"4872","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":40,"title":["Persistence as a Robust Indicator of Medication Adherence-Related Quality and Performance"],"prefix":"10.3390","volume":"18","author":[{"given":"Enrica","family":"Menditto","sequence":"first","affiliation":[{"name":"CIRFF, Center of Pharmacoeconomics and Drug Utilization Research, Department of Pharmacy, University of Naples Federico II, 80131 Naples, Italy"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7137-5737","authenticated-orcid":false,"given":"Caitriona","family":"Cahir","sequence":"additional","affiliation":[{"name":"Data Science Centre, Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7194-8275","authenticated-orcid":false,"given":"Sara","family":"Malo","sequence":"additional","affiliation":[{"name":"Preventive Medicine and Public Health Department, Zaragoza University, Fundaci\u00f3n Instituto de Investigaci\u00f3n Sanitaria de Arag\u00f3n (IIS Arag\u00f3n), 50009 Zaragoza, Spain"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7293-701X","authenticated-orcid":false,"given":"Isabel","family":"Aguilar-Palacio","sequence":"additional","affiliation":[{"name":"Preventive Medicine and Public Health Department, Zaragoza University, Fundaci\u00f3n Instituto de Investigaci\u00f3n Sanitaria de Arag\u00f3n (IIS Arag\u00f3n), 50009 Zaragoza, Spain"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6575-1698","authenticated-orcid":false,"given":"Marta","family":"Almada","sequence":"additional","affiliation":[{"name":"UCIBIO\/REQUIMTE, Competences Centre on Active and Healthy Ageing of the University of Porto, Porto4Ageing, Faculty of Pharmacy, University of Porto, 4099-002 Porto, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1158-1480","authenticated-orcid":false,"given":"Elisio","family":"Costa","sequence":"additional","affiliation":[{"name":"UCIBIO\/REQUIMTE, Competences Centre on Active and Healthy Ageing of the University of Porto, Porto4Ageing, Faculty of Pharmacy, University of Porto, 4099-002 Porto, Portugal"}]},{"given":"Anna","family":"Giardini","sequence":"additional","affiliation":[{"name":"IT Department, Istituti Clinici Scientifici Maugeri IRCCS Pavia, Pavia 27100, Italy"}]},{"given":"Mar\u00eda","family":"Gil Peinado","sequence":"additional","affiliation":[{"name":"Drug Information Centre and Pharmaceutical Care Department, Muy Ilustre Colegio Oficial de Farmac\u00e9uticos de Valencia (MICOF Valencia), 46003 Valencia, Spain"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3649-5167","authenticated-orcid":false,"given":"Mireia","family":"Massot Mesquida","sequence":"additional","affiliation":[{"name":"Servei d\u2019Atenci\u00f3 Prim\u00e0ria Vall\u00e8s Occidental, Institut Catal\u00e0 de la Salut, 08202 Barcelona, Spain"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3357-5655","authenticated-orcid":false,"given":"Sara","family":"Mucherino","sequence":"additional","affiliation":[{"name":"CIRFF, Center of Pharmacoeconomics and Drug Utilization Research, Department of Pharmacy, University of Naples Federico II, 80131 Naples, Italy"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8209-8878","authenticated-orcid":false,"given":"Valentina","family":"Orlando","sequence":"additional","affiliation":[{"name":"CIRFF, Center of Pharmacoeconomics and Drug Utilization Research, Department of Pharmacy, University of Naples Federico II, 80131 Naples, Italy"}]},{"given":"Carlos Luis","family":"Parra-Calder\u00f3n","sequence":"additional","affiliation":[{"name":"Group of Research and Innovation in Biomedical Informatics, Biomedical Engineering and Health Economy, Institute of Biomedicine of Seville, IBiS\/Virgen del Roc\u00edo University Hospital\/CSIC\/University of Seville, 41004 Sevilla, Spain"}]},{"given":"Enrique","family":"Pepiol Salom","sequence":"additional","affiliation":[{"name":"International Committee, Muy Ilustre Colegio Oficial de Farmac\u00e9uticos de Valencia (MICOF Valencia), 46003 Valencia, Spain"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6078-2628","authenticated-orcid":false,"given":"Przemyslaw","family":"Kardas","sequence":"additional","affiliation":[{"name":"Medication Adherence Research Centre, Medical University of Lodz, 90-136 Lodz, Poland"}]},{"given":"Bernard","family":"Vrijens","sequence":"additional","affiliation":[{"name":"AARDEX Group &amp; Li\u00e8ge University, 4000 Li\u00e8ge, Belgium"}]}],"member":"1968","published-online":{"date-parts":[[2021,5,3]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"487","DOI":"10.1056\/NEJMra050100","article-title":"Adherence to medication","volume":"353","author":"Osterberg","year":"2005","journal-title":"N. Engl. J. Med."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"216","DOI":"10.1007\/s11606-017-4198-4","article-title":"Advancing the Science and Practice of Medication Adherence","volume":"33","author":"Stirratt","year":"2018","journal-title":"J. Gen. Intern. Med."},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Menditto, E., Orlando, V., De Rosa, G., Minghetti, P., Musazzi, U.M., Cahir, C., Kurczewska-Michalak, M., Kardas, P., Costa, E., and Lobo, J.M.S. (2020). Patient Centric Pharmaceutical Drug Product Design-The Impact on Medication Adherence. Pharmaceutics, 12.","DOI":"10.3390\/pharmaceutics12010044"},{"key":"ref_4","unstructured":"European Commission (2021, February 05). Competition DG 8th Report on the Monitoring of Patent Settlements. Available online: http:\/\/ec.europa.eu\/competition\/sectors\/pharmaceuticals\/inquiry\/index.html."},{"key":"ref_5","unstructured":"World Health Organization (WHO) (2003). Adherence to Long-Term Therapies: Evidence for Action, World Health Organization (WHO)."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"571","DOI":"10.5217\/ir.2018.00033","article-title":"Medication non-adherence in inflammatory bowel diseases is associated with disability","volume":"16","author":"Perry","year":"2018","journal-title":"Intest Res."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"555","DOI":"10.1111\/1756-185X.13549","article-title":"Medication adherence and cost-related medication non-adherence in patients with rheumatoid arthritis: A cross-sectional study","volume":"22","author":"Heidari","year":"2019","journal-title":"Int. J. Rheum. Dis."},{"key":"ref_8","unstructured":"Khan, R., and Socha-Dietrich, K. (2020, September 10). Investing in Medication Adherence Improves Health Outcomes and Health System Efficiency. Available online: http:\/\/www.oecd.org\/officialdocuments\/publicdisplaydocumentpdf\/?cote=DELSA\/HEA\/WD\/HWP."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"431","DOI":"10.1093\/intqhc\/13.6.431","article-title":"Performance indicators from all perspectives","volume":"13","author":"Ibrahim","year":"2001","journal-title":"Int. J. Qual. Health Care"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"377","DOI":"10.1093\/intqhc\/mzg049","article-title":"Conceptual frameworks for health systems performance: A quest for effectiveness, quality, and improvement","volume":"15","author":"Arah","year":"2003","journal-title":"Int. J. Qual. Health Care"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1743","DOI":"10.1001\/jama.1988.03410120089033","article-title":"The Quality of Care: How Can It Be Assessed?","volume":"260","author":"Donabedian","year":"1988","journal-title":"JAMA"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"489","DOI":"10.1093\/intqhc\/13.6.489","article-title":"From a process of care to a measure: The development and testing of a quality indicator","volume":"13","author":"Rubin","year":"2001","journal-title":"Int. J. Qual. Health Care"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"691","DOI":"10.1111\/j.1365-2125.2012.04167.x","article-title":"A new taxonomy for describing and defining adherence to medications","volume":"73","author":"Vrijens","year":"2012","journal-title":"Br. J. Clin. Pharmacol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"30","DOI":"10.7326\/M18-0543","article-title":"ESPACOMP Medication Adherence Reporting Guideline (EMERGE)","volume":"169","author":"Zullig","year":"2018","journal-title":"Ann. Intern. Med."},{"key":"ref_15","first-page":"1280","article-title":"Measurement of Adherence in Pharmacy Administrative Databases: A Proposal for Standard Definitions and Preferred Measures","volume":"40","author":"Hess","year":"2006","journal-title":"Ann. Pharm."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e18150","DOI":"10.2196\/18150","article-title":"The Need to Develop Standard Measures of Patient Adherence for Big Data: Viewpoint","volume":"22","author":"Kardas","year":"2020","journal-title":"J. Med. Internet Res."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Moreno-Juste, A., Poblador-Plou, B., Aza-Pascual-Salcedo, M., Gonz\u00e1lez-Rubio, F., Malo, S., Librero L\u00f3pez, J., Pico-Soler, V., Gim\u00e9nez Labrador, E., Mucherino, S., and Orlando, V. (2020). Initial Therapy, Regimen Change, and Persistence in a Spanish Cohort of Newly Treated Type 2 Diabetes Patients: A Retrospective, Observational Study Using Real-World Data. Int. J. Environ. Res. Public Health, 17.","DOI":"10.3390\/ijerph17103742"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"2464","DOI":"10.1111\/bcp.14075","article-title":"The association between medication non-adherence and adverse health outcomes in ageing populations: A systematic review and meta-analysis","volume":"85","author":"Walsh","year":"2019","journal-title":"Br. J. Clin. Pharmacol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"690","DOI":"10.1016\/j.jval.2015.02.015","article-title":"Initial Medication Adherence\u2014Review and Recommendations for Good Practices in Outcomes Research: An ISPOR Medication Adherence and Persistence Special Interest Group Report","volume":"18","author":"Hutchins","year":"2015","journal-title":"Value Health"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"891","DOI":"10.1016\/j.jval.2013.04.014","article-title":"A systematic literature review of psychosocial and behavioral factors associated with initial medication adherence: A report of the ISPOR medication adherence & persistence special interest group","volume":"16","author":"Zeber","year":"2013","journal-title":"Value Health"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"e001537","DOI":"10.1136\/bmjdrc-2020-001537","article-title":"Long-term metformin adherence in the Diabetes Prevention Program Outcomes Study","volume":"8","author":"Walker","year":"2020","journal-title":"BMJ Open Diabetes Res. Care"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"565","DOI":"10.1002\/pds.1230","article-title":"Methods for evaluation of medication adherence and persistence using automated databases","volume":"15","author":"Andrade","year":"2006","journal-title":"Pharmacoepidemiol. Drug Saf."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1111\/j.1524-4733.2006.00139.x","article-title":"A Checklist for Medication Compliance and Persistence Studies Using Retrospective Databases","volume":"10","author":"Peterson","year":"2007","journal-title":"Value Health"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"275","DOI":"10.1146\/annurev-pharmtox-011711-113247","article-title":"Adherence to medications: Insights arising from studies on the unreliable link between prescribed and actual drug dosing histories","volume":"52","author":"Blaschke","year":"2012","journal-title":"Annu. Rev. Pharmacol. Toxicol."},{"key":"ref_25","first-page":"449","article-title":"Estimating medication persistency using administrative claims data","volume":"11","author":"Sikka","year":"2005","journal-title":"Am. J. Manag. Care"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1290","DOI":"10.3389\/fphar.2018.01290","article-title":"A Systematic Review of Medication Adherence Thresholds Dependent of Clinical Outcomes","volume":"9","author":"Baumgartner","year":"2018","journal-title":"Front. Pharmacol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1329","DOI":"10.1080\/03007995.2017.1321534","article-title":"Different approaches to the assessment of adherence and persistence with cardiovascular-disease preventive medications","volume":"33","author":"Malo","year":"2017","journal-title":"Curr. Med. Res. Opin."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1381","DOI":"10.1007\/s00228-016-2106-1","article-title":"Adherence to antidepressants among women and men described with trajectory models: A Swedish longitudinal study","volume":"72","author":"Sundell","year":"2016","journal-title":"Eur. J. Clin. Pharmacol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1105","DOI":"10.1002\/pds.3787","article-title":"Association between trajectories of statin adherence and subsequent cardiovascular events","volume":"24","author":"Franklin","year":"2015","journal-title":"Pharmacoepidemiol. Drug Saf."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"953","DOI":"10.1002\/pds.4012","article-title":"The association between trajectories of endocrine therapy adherence and mortality among women with breast cancer","volume":"25","author":"Winn","year":"2016","journal-title":"Pharmacoepidemiol. Drug Saf."},{"key":"ref_31","first-page":"1138","article-title":"Medication Adherence Trajectories: A Systematic Literature Review","volume":"26","author":"Alhazami","year":"2020","journal-title":"J. Manag. Care Spec. Pharm."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"920","DOI":"10.1111\/dom.13603","article-title":"Adherence, persistence, glycaemic control and costs among patients with type 2 diabetes initiating dulaglutide compared with liraglutide or exenatide once weekly at 12-month follow-up in a real-world setting in the United States","volume":"21","author":"Mody","year":"2019","journal-title":"Diabetes Obes. Metab."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"233","DOI":"10.1093\/jamiaopen\/ooaa007","article-title":"Medication adherence for atrial fibrillation patients: Triangulating measures from a smart pill bottle, e-prescribing software, and patient communication through the electronic health record","volume":"3","author":"Toscos","year":"2020","journal-title":"JAMIA Open"},{"key":"ref_34","unstructured":"World Health Organisation (2021, April 09). The Determinants of Health [Online]. Available online: http:\/\/www.who.int\/hia\/evidence\/doh\/en\/."},{"key":"ref_35","first-page":"1282","article-title":"Integrating E-Prescribing and Pharmacy Claims Data for Predictive Modeling: Comparing Costs and Utilization of Health Plan Members Who Fill Their Initial Medications with Those Who Do Not","volume":"26","author":"Chang","year":"2020","journal-title":"J. Manag. Care Spec. Pharm."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1975","DOI":"10.2147\/PPA.S164819","article-title":"Adherence to chronic medication in older populations: Application of a common protocol among three European cohorts","volume":"12","author":"Menditto","year":"2018","journal-title":"Patient Prefer. Adherence"},{"key":"ref_37","first-page":"CD000011","article-title":"Interventions for enhancing medication adherence","volume":"2014","author":"Nieuwlaat","year":"2014","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"91","DOI":"10.3389\/fphar.2013.00091","article-title":"Determinants of patient adherence: A review of systematic reviews","volume":"4","author":"Kardas","year":"2013","journal-title":"Front. Pharmacol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"e016982","DOI":"10.1136\/bmjopen-2017-016982","article-title":"Economic impact of medication non-adherence by disease groups: A systematic review","volume":"8","author":"Cutler","year":"2018","journal-title":"BMJ Open"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"e21659","DOI":"10.2196\/21659","article-title":"Artificial Intelligence-Powered Smartphone App to Facilitate Medication Adherence: Protocol for a Human Factors Design Study","volume":"9","author":"Roosan","year":"2020","journal-title":"JMIR Res. Protoc."},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Melis, R., Marengoni, A., Angleman, S., and Fratiglioni, L. (2014). Incidence and Predictors of Multimorbidity in the Elderly: A Population-Based Longitudinal Study. PLoS ONE, 9.","DOI":"10.1371\/journal.pone.0103120"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1016\/S0140-6736(12)60240-2","article-title":"Epidemiology of multimorbidity and implications for health care, research, and medical education: A cross-sectional study","volume":"380","author":"Barnett","year":"2012","journal-title":"Lancet"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"213","DOI":"10.1016\/j.archger.2018.06.018","article-title":"Polypharmacy prevalence among older adults based on the survey of health, ageing and retirement in Europe","volume":"78","author":"Giardini","year":"2018","journal-title":"Arch. Gerontol. Geriatr."},{"key":"ref_44","doi-asserted-by":"crossref","unstructured":"Masnoon, N., Shakib, S., Kalisch-Ellett, L., and Caughey, G.E. (2017). What is polypharmacy? A systematic review of definitions. BMC Geriatr., 17.","DOI":"10.1186\/s12877-017-0621-2"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"192","DOI":"10.1007\/s11096-013-9891-8","article-title":"A method for calculating adherence to polypharmacy from dispensing data records","volume":"36","author":"Arnet","year":"2014","journal-title":"Int. J. Clin. Pharm."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"381","DOI":"10.1111\/j.1399-3046.2005.00356.x","article-title":"Growing pains: Non-adherence with the immunosuppressive regimen in adolescent transplant recipients","volume":"9","author":"Dobbels","year":"2005","journal-title":"Pediatr. Transplant."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"112780","DOI":"10.1016\/j.psychres.2020.112780","article-title":"Brief interventions for improving adherence in schizophrenia: A pilot study using electronic medication event monitoring","volume":"285","author":"Tessier","year":"2020","journal-title":"Psychiatry Res."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"827","DOI":"10.1001\/jamainternmed.2015.0324","article-title":"Reducing inappropriate polypharmacy: The process of deprescribing","volume":"175","author":"Scott","year":"2015","journal-title":"JAMA Intern. Med."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"1311","DOI":"10.1016\/S0149-2918(01)80110-7","article-title":"Patient compliance and persistence with antihyperglycemic drug regimens: Evaluation of a medicaid patient population with type 2 diabetes mellitus","volume":"23","author":"Dailey","year":"2001","journal-title":"Clin. Ther."},{"key":"ref_50","doi-asserted-by":"crossref","unstructured":"Car, J., Tan, W.S., Huang, Z., Sloot, P., and Franklin, B.D. (2017). eHealth in the future of medications management: Personalisation, monitoring and adherence. BMC Med., 15.","DOI":"10.1186\/s12916-017-0838-0"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"435","DOI":"10.1016\/j.rmed.2010.09.006","article-title":"Treatment of COPD: Relationships between daily dosing frequency, adherence, resource use, and costs","volume":"105","author":"Toy","year":"2011","journal-title":"Respir. Med."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"870","DOI":"10.3389\/fphar.2019.00870","article-title":"Treatment Patterns of Diabetes in Italy: A Population-Based Study","volume":"10","author":"Menditto","year":"2019","journal-title":"Front. Pharmacol."},{"key":"ref_53","first-page":"434","article-title":"Persistence with Statins in Primary Prevention of Cardiovascular Disease: Findings from a Cohort of Spanish Workers","volume":"73","author":"Malo","year":"2020","journal-title":"Rev. Esp. Cardiol."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"2369","DOI":"10.1210\/jc.2018-00325","article-title":"Persistence of Diabetes and Hypertension After Multimodal Treatment of Acromegaly","volume":"103","author":"Vargas","year":"2018","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"1783","DOI":"10.1080\/03007995.2017.1367275","article-title":"Long-term persistence with single-pill, fixed-dose combination therapy versus two pills of amlodipine and perindopril for hypertension: Australian experience","volume":"33","author":"Simons","year":"2017","journal-title":"Curr. Med. Res. Opin."}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/18\/9\/4872\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T05:56:53Z","timestamp":1760162213000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/18\/9\/4872"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,5,3]]},"references-count":55,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2021,5]]}},"alternative-id":["ijerph18094872"],"URL":"https:\/\/doi.org\/10.3390\/ijerph18094872","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,5,3]]}}}