General introduction 13 instrument to assess adherence in patients with chronic diseases following rehabilitation. If adherence can be measured objectively, it would then be of added value if the probability of adherence could also be predicted. This would enable health care providers to discriminate between adherent and non-adherent patients. Based on this, it can be determined whether someone is capable of more self-management or whether adherence needs to be increased first. The question here is whether adherence actually influences self-management in a positive way. Study population in this thesis Despite substantial progress in reducing the global impact of many chronic diseases, including heart disease and cancer [27], morbidity and mortality due to chronic respiratory disease continues to increase. This increase is driven primarily by the growing burden of chronic obstructive pulmonary disease (COPD) [27]. The prevalence of COPD increased by almost 40% between 1990 and 2017, and by 2017 COPD had become the third leading cause of death globally [27]. Based on demographic trends, the absolute number of patients with COPD is expected to increase by 31% between 2015 and 2040 in the Netherlands [28]. Given the increase in the expected number of patients with COPD, the morbidity and mortality of the disease, the lack of awareness for COPD [29], and the great pressure the disease puts on the healthcare system, patients with COPD were chosen as study population in this thesis (which does not alter the fact that the topic of this thesis is applicable to patients with all kind of chronic diseases). More specifically, people with COPD attending pulmonary rehabilitation for at least one month were chosen. Patients already attending pulmonary rehabilitation understand what is expected of them regarding a more active lifestyle, and they are therefore ideally suited for more focus on self-management with an emphasis on adherence. Interdisciplinary nature of the thesis The content of this thesis is interdisciplinary in nature. Background of pathology and physiology of COPD is the starting point, complemented by physiotherapeutic knowledge regarding pulmonary rehabilitation. In the development of the intervention (the PATCH tool) epidemiological knowledge and knowledge of behavior and psychology come together.
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