189 Chapter 7 This chapter is a supplement to chapter 6: it describes an analysis of the determinants that could potentially predict adherence, and describes some potential interventions, based on the predictors found, to improve adherence. Variables that had significant (p < 0.05) correlations with exercise adherence were retained for a hierarchical linear multiple regression analysis (HMRA). Independent predictors of exercise adherence in the final model were: education (b = 1.39; p = 0.01), MRC (b = -1.23; p = 0.001), intention (b = 0.63; p = 0.000), depression (b = -0.53; p = 0.000) and alliance (b = 0.21; p = 0.000). Further, exercise intention could be explained by perceived behavioral control (PBC) (b = 0.66, p = 0.000), attitude (b = 0.09, p = 0.01) and alliance (b = -0.08, p = 0.000). Potential interventions for improving attitude are teach-back, Motivational Interviewing (MI) and Cognitive Behavioral Therapy (CBT); for improving PBC these are also teach-back, MI and CBT; for decreasing perceived dyspnea teach-back can be used specifically applied to the Breathing, Thinking, Functioning (BTF) model; for decreasing depressive symptoms CBT might be used as well as exercise itself; and finally, both exercise intention and exercise adherence can be directly influenced by optimal alliance. Chapter 8 This chapter describes a protocol for a hybrid type 1 effectiveness-implementation study. It will be a 12-month study, performed in primary physiotherapy practices in The Netherlands. The aim is to include 108 patients with COPD who have been receiving pulmonary rehabilitation for at least six weeks (from six weeks, according to the KNGF Guideline COPD, the maintenance phase starts). The study will evaluate the effects of increased self-management on relevant outcomes (adherence, exercise capacity, disease burden, health-related quality of life, MRC score and lung attacks); at the start of the study, according to guideline recommendations, the number of supervised treatments will be halved and selfmanagement will be introduced. Also, the predictive validity of the PATCH tool will be examined, while information on feasibility and adoption of increased selfmanagement and use of the PATCH tool will be obtained through semi-structured interviews with patients and physiotherapists. Chapter 9 This chapter outlines and discusses the results of this thesis by describing the rationale and main findings and provides a reflection on the three themes that can be distinguished 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. Regarding the data collection, there are strengths and limitations. Strengths are that data collection was conducted in both the Netherlands and Belgium and that
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