Measuring adherence to pulmonary rehabilitation 35 Introduction From a rehabilitation context, adherence has been defined as an ‘active, voluntary collaborative involvement of the patient in a mutually acceptable course of behavior to produce a desired preventative or therapeutic result’ [1]. The behaviors that constitute exercise adherence may vary, and largely depends on the type of injury or condition of presenting patients. These behaviors may include attendance at clinic appointments, the extent to which patients follow the prescribed treatment, and the communication with their healthcare provider about their recovery in order to receive feedback about their home-based rehabilitation activities [2]. Rehabilitation more and more involves self-management, and requires effort from patients themselves in following prescribed exercises at home. This makes adherence increasingly important [3]. Adherence is important in many aspects of healthcare as it is related to clinical outcomes, and to the (economic) burden for healthcare providers [4]. Patients who fail to adhere to the prescribed exercises, may experience prolonged duration of treatment and less favorable treatment results [5]. Also, the increase in chronic diseases makes adherence important for all stakeholders in the healthcare system [3]. To keep healthcare affordable and improving patient outcomes, attention must be paid to adherence [6]. One chronic disease where adherence is of particular importance is chronic obstructive pulmonary disease (COPD). Fewer than half of treatments for COPD are taken as prescribed [7]. The management of a disease like COPD is difficult because prescribed exercises largely take place at home, with patients and their caregivers making decisions as to whether exercises should be started or continued, often without consulting their healthcare provider [8]. As a result, it is often not clear to professionals whether patients are adherent or not. Professionals tend to make their own judgements about the extent of the suspected nonadherence in patients by asking or by observing treatment progress [9]. These judgements may be incorrect; their validity is uncertain. Therefore, a standardized instrument is needed to quantify the extent and reasons for non-adherence [9] as early as possible. On the basis of early signals, the treatment might be adapted to the specific needs of an individual patient or measures can be taken to improve adherence [10]. Literature shows that some instruments are available to measure adherence to exercise interventions [11]. Of the instruments mentioned, only two appear to be valid and reliable: the Sport Injury Rehabilitation Adherence Scale (SIRAS) [12] and the Rehabilitation Adherence Measure for Athletic Training (RAdMAT) [13]. However, in the context of measuring adherence, an additional requirement for the instrument is that it must be multidimensional, as adherence is a multidimensional
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