Chapter 7 132 Nonetheless, the findings of these analyses suggest that healthcare providers should obtain information about their patients’ attitudes, PBC, depressive symptoms, alliance, MRC-score, and education level, when their patients with COPD are following PR. In doing so, they can target the specific constructs to increase their patients’ exercise intention and exercise adherence during PR. Education level may not be an influenceable variable, but this does emphasize the importance of providing understandable and unambiguous information regarding exercise to prevent and overcome the negative effects of a lower level of education. Since the TPB constructs had limited value in predicting exercise adherence, interventions based on additional constructs must be considered to influence exercise adherence. Potential interventions Teach Back With respect to education, healthcare providers might use behavior change techniques that support patients not only to understand complex health information, but also to apply this information in everyday life [16]. The ability to understand and use health information is a core component of health literacy, a concept which is consistently associated with health outcomes [17]. One behavior change technique that healthcare providers can use for this purpose is ‘teach-back’. Teach-back involves asking patients to explain in their own words what a healthcare provider just has told them. Any misunderstanding is then clarified by the healthcare provider and understanding is checked again. This process continues until the patient can correctly recall the information that was given [17]. Use of teach-back has been shown to improve knowledge, skills and self-care abilities in patients with chronic diseases [18]. So, when applying teach-back, healthcare providers may be able to improve the attitude and PBC of a patient, so they understand in more depth the reasons of the behavior change they have to make, and become more convinced that they are able to make the change. Teach-back might also be used to improve perceived dyspnea (MRC-score). Teachback is then used to impart specific knowledge to the patient, namely that of the Breathing, Thinking, Functioning (BTF) model. The BTF model is a tool to help healthcare providers understand and manage chronic dyspnea. The model is based on three predominant cognitive and behavioral reactions to dyspnea that, by causing vicious cycles, worsen and maintain the symptom [19]. 1. Patients with dyspnea experience a sense of ‘needing more air’ and, therefore, may consciously or subconsciously increase their respiratory rate, further increasing the work of breathing and intensifying dyspnea. 2. Anxiety or fear caused by dyspnea can, in turn, augment the perception of dyspnea. This vicious cycle can lead to a rapidly escalating sense of panic, which most patients with dyspnea experience at some point. In addition, anxiety increases the respiratory rate and can so further increase the respiratory demand [19]. 3. As dyspnea is really unpleasant, it is natural to
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