Measuring adherence in clinic-based physiotherapy 21 Introduction Non-adherence to treatment is a problem across therapeutic areas, also including physiotherapy, with non-adherence rates ranging from 25% to 50% [1, 2]. Poor adherence limits the potential of physiotherapeutic rehabilitation to improve patients’ health and quality of life. Furthermore, this non-adherence has been associated with substantial costs (for patients and society), including avoidable morbidity, increased hospital admissions, and prolonged hospital stays [1, 2]. For example, non-adherent patients with type II diabetes can have annual inpatient costs 41% higher compared to adherent patients [3]. Significant costs can be avoided by increasing adherence [3]. So, non-adherence to physiotherapeutic rehabilitation is a problem of increasing concern to all stakeholders in the health system. At the same time, adherence is the most important factor of treatment that can be influenced to achieve positive treatment outcomes [1]. In this study adherence is defined as the extent to which a person’s behavior, taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider [4]. In physiotherapy, adherence is a multi-dimensional concept that could relate to attending appointments, following advice, undertaking prescribed exercises and the performance and frequency of the exercises [5]. Physiotherapists almost always assume that patients are motivated to follow treatment because of their injury/disease. However, literature shows that this assumption might be incorrect [6, 7]. The determinants of adherence in physiotherapy (inactive or moderate active lifestyle at baseline, low adherence to exercise, low self-efficacy, depression, anxiety, helplessness, poor social support, and greater number of perceived barriers to exercise) suggest that adherence is a behavioral problem observed in patients, but with causes beyond the patient [5, 7]. In every situation in which patients have to take responsibility of their own treatment, non-adherence is likely. This is especially true for patients with chronic diseases. Non-adherence increases with the duration and complexity of a treatment, both of which are high for chronic diseases [7]. Poor adherence to longterm therapy severely compromises the effectiveness of treatment. This is a critical health issue, because chronic diseases are increasing in The Netherlands. In the Netherlands (as in western society), the prevalence of chronic diseases is increasing due to the rapid aging of the population and the greater longevity of people with chronic diseases. Also, the prevalence of multi-morbidity (the presence of multiple diseases in the same individual) is rising [8]. Because of the increase of patients with chronic diseases, physiotherapists in the Netherlands have noticed an increase of these patients in their practice. This number will only further increase in the future [9].
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