Prognostic factors of adherence 57 Introduction Chronic diseases represent the major share of burden of disease in Europe and are responsible for 86% of all deaths [1]. There is accumulating evidence that in patients with chronic diseases exercise therapy is effective in improving the prognostic risk factor profile and, in certain diseases, in delaying mortality [2]. According to the systematic review of Jolliffe et al. [3] exercise therapy in cases of documented coronary heart disease reduced all-cause mortality by 27% and total cardiac mortality by 31%. Exercise therapy is defined as systemic execution of planned physical movements, postures, or activities intended to enable the patient to reduce risk, enhance function, remediate or prevent impairment, optimize overall health, and improve fitness and well-being [4]. While exercise therapy shows encouraging results for the treatment and prevention of adverse health outcomes in patients with chronic diseases, patients must adhere to the prescribed program in order to benefit from the exercise intervention [5]. It is well-documented that longterm adherence to exercise therapy (i.e. adherence over a long period of time - lifelong - to control the disease [5]) is suboptimal in patients with chronic diseases and especially in home-based exercise therapy [2, 5]. The WHO outlined that there are multiple factors underlying adherence, and that these factors can be classified in five dimensions affecting adherence in the general population; patient-related, social/economic, therapy-related, condition-related and health system factors [6]. These five dimensions can provide an important framework (systems approach) for conceptualizing the issue of non-adherence with chronic diseases [7]. Non-adherence to exercise therapy, often exceeding 50% in patients with chronic diseases [5], is a problem which does not only effect the patient but also the health care system. Non-adherence entails high costs, both for patient and society, including avoidable morbidity, increased hospital admissions, and prolonged hospital stays [8]. For example, a study in the Netherlands demonstrated that a 22% increase in adherence to exercise therapy as a first treatment strategy in Dutch patients with intermittent claudication (IC) resulted in an estimated 6% lower cost for IC treatment [9]. To keep healthcare affordable and improving patient outcomes, focus on adherence is increasingly important [10]. To support successful implementation of home-based exercise programs for patients with chronic diseases, we must first identify what factors influence adherence to these programs. If these factors are known, this information can inform the design of future home-based exercise programs as well as the identification of individuals who may require extra support to benefit from prescribed exercise. Previous research identified a wide variety of prognostic factors potentially associated with adherence to physiotherapy [11, 12] and not to prescribed exercise therapy, or studied factors associated with adherence in older people, or studied a single aspect of exercise adherence [13]. In addition, the
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