Measuring adherence to pulmonary rehabilitation 49 Strengths and limitations The strengths of this study are inclusion of patients from 53 physiotherapy practices and from patient-organizations in The Netherlands and Belgium, which enhances the generalizability of the study results. Another strength is the use of parallel analysis; parallel analysis is considered one of the best options for determining the factors to retain in factor analysis because it provides a statistically rigorous approach. It addresses the issue of overestimating the number of factors to retain, which is a common challenge in exploratory factor analysis. Finally, a strength of this study is that prospective data were collected in a real-life setting of primary physiotherapy practices, increasing ecological validity. This study also has some limitations. This study was conducted during the COVID19 pandemic and may have affected motivation of patients for physiotherapy and the way physiotherapists work. Counselling may not always have been able to take place physically, but also online and may have influenced the communication items. Implications No Dutch instrument of exercise adherence was available. The RAdMAT-NL could be used as an interim assessment instrument of exercise adherence for patients who are not progressing as expected. Low scores on the RAdMAT-NL may indicate the need for interventions to enhance patient’s adherence. According to the American College of Sports Medicine (ACSM) guidelines, a score of at least 85% must be achieved to be adherent to the rehabilitation program [35]. The RAdMATNL may also be used or studied in relation to the patient psychological determinants of adherence, such as motivation and perceived control. That is, while the RAdMAT-NL provides the professional’s perspective on the patient’s adherence, the psychological determinants may provide the patient perspective, and together they may predict adherence even better. Conclusions The RAdMAT-NL showed good structural validity and convergent validity in patients with COPD who were undertaking pulmonary rehabilitation in a primary physiotherapy practice in The Netherlands and Belgium. A two-factor structure was demonstrated; Participation and Communication. Without the communication items (item 6-8) the RAdMAT-NL can be used as a single measure of adherence. With only 16-items in a simple format, the RAdMAT-NL is also relatively easy to use, whether by healthcare providers in clinical practice or for research purposes.
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