Supplement prediction model 133 avoid it by reducing activity. However, inactivity leads to muscle deconditioning, with reduced oxidative capacity, and muscle fiber atrophy. This increases the demand on the respiratory system, and worsens dyspnea further [19]. When healthcare providers use teach-back to know if their patients understand the BTF model, patients might be capable of reducing their MRC-score and manage their dyspnea. This BTF model reveals the complexity of the perceptions underlying coping with COPD and adherence, that include perceptions on physical sensations, danger, impulse control and knowledge on physical effects of inactivity. From a theoretical point of view these factors influence patients’ attitude and PBC. Motivational Interviewing Motivational interviewing (MI) is a patient-centered conversational approach to behavior change proposed by Miller and Rollnick [20], and can be used to improve exercise adherence. The approach encourages healthcare providers to take a collaborative stance, avoid provoking resistance, elicit the patient’s own motivations for change, and focus their attention on resources and planning for carrying out these changes [20]. The aim for healthcare providers is to help guide a conversation about change, and activating patients’ intrinsic motivation. This ‘guiding’ approach is in contrast with both directing the patient (imposing to be more physically active, pushing against resistance) and with avoiding the subject of change altogether. To apply this strategy three dimensions can be assessed: 1. Importance (patient’s attitude towards exercise): How important is it to the patient to become more physically active? Patients often know exercising is good for one’s health. However, patients may not feel that change is important, that change could feel worse than staying the same (e.g., more feelings of dyspnea and fatigue), or that change is less important right now than other priorities. 2. Confidence (patient’s perceived behavioral control): How confident does the patient feel that they can be more physically active? A patient who has had an unsuccessful attempt to maintain exercise may feel unlikely to succeed on another attempt, or may feel they are in a better position to make sustained change than in the past. 3. Readiness (patient’s exercise intention): How much does the patient feel that they can start the change process now? A healthcare provider might ask a patient to rate on a scale from 010, with 10 being the highest, how ready they feel to become more physically active. When a patient responds with 5 out of 10, the healthcare provider can ask why the motivation is not lower, e.g., 3 or 4. The patient then has a chance to explain the motivation that is already present. This motivation can be explored and reinforced; the healthcare provider can ask the patient what they need for motivation to become a 7 [21]. Depressive symptoms and patients’ beliefs and interpretations about behavior change (attitude towards exercise) can influence their exercise adherence. Patients may not feel an immediate benefit from changes in their medical regimen [21], their attitude towards exercise is negative. For example, patients who already experience many symptoms from their COPD (MRC score 3-5) may possibly think that (more) physical activity will give them more dyspnea and fatigue (their attitude
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