Chapter 7 134 belief). By using MI, a healthcare provider can play a critical role in the behavior change (in creating a positive attitude) of the patient. By increasing patient awareness through information, education, and personal feedback, the healthcare provider may influence patient’s attitude, perceived behavioral control (and thus exercise intention), and possibly perceived dyspnea (MRC-score). A collaborative approach is recommended, in which patient and healthcare provider form a partnership in developing a plan for behavior change [20]. The latter again highlights the importance of alliance. Alliance Improving alliance is a possible intervention to improve exercise intention and exercise adherence [5]. Poor exercise adherence might flow from an impaired doctor-patient relationship e.g., when patients feel unheard, disrespected, or otherwise out of partnership with their healthcare provider [22]. Alliance has a direct impact on patient satisfaction; “the degree to which the individual regards the healthcare service or product or the manner in which it is delivered by the provider as useful, effective, or beneficial” [23]. There are 4 elements that form alliance, and the nature of this alliance has an impact on patient satisfaction and thus on exercise adherence; trust, knowledge, regard, and loyalty [23]. Patients who trust and “like” their healthcare provider have higher levels of satisfaction. When healthcare providers have knowledge about patients concerns and address patients’ expectations, patient satisfaction increases as it does when healthcare providers allow patients to give information. Healthcare providers’ friendliness, warmth, emotional support, and caring (regard) are associated with patient satisfaction. Patients feel more satisfied when healthcare providers offer continued support (loyalty); continuity of care improves patient satisfaction [23]. When a new patient comes for PR, all four of these elements are not yet present. Therefore, it is important for a healthcare provider to be aware of this and invest in alliance (invest in trust, knowledge, regard, and loyalty). When a patient has been under treatment for a longer period of time, there is a risk that the alliance will diminish. One way to boost the alliance, as well as patient outcomes, is by gathering patient feedback and incorporating it into treatment [24, 25]. Cognitive Behavioral Therapy The fact that TPB has limitations in explaining behavior is partly because cognitions and behaviors change over time. So, the interactions between behavior and cognition may be dynamic rather than static [26]. Patients respond to illness in a dynamic way based on their interpretation and evaluation of the illness. The choice of a particular coping response is influenced by whether it makes sense in the light of their own ideas about the illness and personal experience of symptoms [26]. A reason for patients with COPD not being adherent to exercise may therefore be cognitive and requires a cognitive solution. So, a cognitive behavior model, like the self-regulation of exercise maintenance model, may affect behavior. The selfregulation of exercise maintenance model suggests that exercise behavior is
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