General introduction 11 Adherence Adherence has been defined as: “the extent to which a person’s behavior in therapeutical interventions, as e.g., the use of medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider” [10]. Adherence is a complex multi-dimensional construct (patient-related, social/economic, therapy-related, condition-related and health system dimension) [7] that can be indirectly observed through a collection of related events such as attendance at clinic appointments, the extent to which patients follow their prescribed treatment and their communication with their healthcare provider about their recovery in order to provide feedback about their home-based healthcare activities [11]. Non-adherence to appropriately prescribed treatment is a global health problem in healthcare and of relevance to all stakeholders, as described above [7]. Not only society, but especially patients themselves, benefit from adherence. Nonadherence might prevent patients from gaining access and exposure to the best treatment [12], and this may be particularly problematic in chronic conditions, including cardiovascular disease, cancer and chronic obstructive pulmonary disease (COPD) [13]. The number of patients with these chronic diseases is increasing in developed countries [14]. Increasing numbers of patients with chronic diseases are causing greater medical expenses both for society and for the patients themselves [14]. Patients with these common chronic conditions are high utilizers of medical services, have a reduced health related quality of life, experience functional limitations, and are at risk of premature death [13]. These patients also need support to prevent problems from developing and avoid having to manage complications [7]. Physical exercise is in most cases an important aspect of the treatment of chronic diseases [13]. However, many patients often have problems adhering to their prescribed exercise program [15]: 50% of patients with a chronic condition do not adhere to their treatment recommendations [7]. In general, exercise programs that extend over a long duration are more likely to lead to poor adherence [16]. This is because adherence in chronic illness entails a specific pattern of behavior, i.e. performing a behavior over a long period of time to manage the disease as recommended by a healthcare provider [7]. Attention to non-adherence may have a far greater impact on the health of patients with chronic diseases, specifically in patients with COPD [17], than any improvement in specific medical and paramedical treatments [12]. The most effective treatment will be of little use to patients if they have insufficient motivation and competences to adhere to the treatment [18]. When patients adhere to evidence-based interventions, such as, e.g., pulmonary rehabilitation (PR) , this may result in more effective treatments [7].
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