Chapter 9 166 General discussion In the current healthcare system, there is a call for effective and efficient healthcare [1]. It is already known that adherence is an important determinant with respect to costs and outcomes of healthcare [1]. The aim of this thesis was to extend this knowledge with specific knowledge regarding exercise adherence in people with chronic (obstructive pulmonary) disease; how can exercise adherence be measured, predicted and potentially contribute to increased self-management? Using the studies in this thesis, the knowledge generated can be transferred, used for further scientific research and possibly applied in practice. First, the rationale and the main findings of this thesis will be pointed out, followed by a reflection on the three themes that can be identified in this thesis: 1. Data collection, 2. Development and validation of a measurement to measure exercise adherence, and 3. Development and use of an exercise adherence prediction model. Finally, recommendations for further research will be provided and an overall conclusion will be formulated. Rationale and main Þndings Attention to self-management in patients with chronic diseases is becoming increasingly important to provide effective and efficient care [1]. Self-management can be defined as ‘actions that individuals, families, and communities engage in to promote, maintain, or restore health and cope with illness and disability, with or without the support of health professionals, and including but not limited to selfprevention, self-diagnosis, self-medication, and coping with illness and disability’ [2]. This definition encompasses a range of self-management methods and approaches, one of the most important for self-management of chronic diseases being long-term adherence [3]. Long-term adherence in self-management can be conceptualized by three components: 1. Initiation: When the patient starts a lifestyle behavior change in accordance with his healthcare provider; 2. Implementation: The extent to which a patient’s behavior corresponds with agreed recommendations from his healthcare provider; 3. Persistence: The time from initiation to discontinuation [4]. Non-adherence can occur in any of these phases, and may change over time in patients. So, appropriate attention should be paid to patients’ level of adherence, as reduced adherence attenuates the benefits of the behavior change, and may negatively impact self-management and thus health outcomes [3]. To determine whether someone is adherent or not, adherence must be measurable. As there is no reference standard for measuring exercise adherence (the best available method for establishing standardized exercise adherence), no recommendations are currently made from the literature for a specific instrument to measure adherence [5]. Only one multi-dimensional instrument that captures the
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