title: Level of, and factors affecting adherence to prescribed exercise in people with spondyloarthritis
Creators: name: McDonald, Marie Therese
Publisher: name: University of Glasgow
Year: 2021
Subjects: subject: Adherence, physiotherapy, spondyloarthritis, exercise, web-based.

description: Background: Spondyloarthritis is a group of chronic inflammatory musculoskeletal diseases for which exercise is considered an essential part of their management. Adherence is a primary determinant of the effectiveness of any intervention and can be influenced by multiple factors. The World Health Organisation proposes that when studying adherence, an approach where adherence is determined by interplay of factors relating to five construct; socioeconomic, healthcare, condition, treatment and patient-related can be used. Currently the level of adherence and factors affecting adherence to prescribed physiotherapy programmes in people with SpA is unknown. Objectives: The aim of the research within this thesis was to investigate the level of, and factors affecting, adherence in people with SpA. Methods: Three studies were undertaken. Firstly, a systematic review of the current literature investigating adherence to prescribed exercise in SpA. Secondly a cohort study to investigate the level of, and factors affecting, adherence to a web-based physiotherapy programme in patients with axial SpA (axSpA), the prototypic SpA condition. Finally, a survey of physiotherapists in the United Kingdom (UK) delivering prescribed exercise programmes to people with SpA, investigating the factors they perceive as affecting adherence and barriers to adopting methods to improve adherence. Results: The systematic review identified and included ten studies with a total of 690 participants. Rates of adherence ranged from 51% to 95%, and in the main were poorly reported. The interventions and measurement of adherence varied across studies, making comparisons difficult. Two studies identified that adherence was improved following educational programmes and one study identified that higher disease severity and longer diagnostic delays were associated with higher adherence rates. One study indicated supervised group exercise increased adherence to HEP whilst another found no difference. Three linked studies by the same authors with the same participants demonstrated that adherence reduced over time. No study within the systematic review measured adherence to a web-based physiotherapy programme. The cohort study found adherence to web-based physiotherapy exercise in people with axSpA was 27.6% of all sessions for all participants over 12-months. When participants started a session, they were likely to complete all the individual exercises within the session (74% versus 26% of the time). Adherence reduced over the course of the intervention. No quantitative factors were found to influence adherence, however participant interviews found that disease symptoms, getting into a routine and support have an important role in influencing adherence. The online survey identified that physiotherapists believe that adherence to prescribed exercises can be low. There were high levels of agreement of the factors affecting adherence to exercise. Within the WHO-proposed healthcare- related construct, good access to physiotherapy and effective medication for symptom control were perceived to improve adherence. Within the disease- related construct, concurrent mental health problems, high disease symptoms and multiple co-morbidities were considered to reduce adherence. Within the socio-economic domain, support increased adherence, while social deprivation reduced adherence. Within the person related construct, the belief the exercise would help and being physically active improved adherence, whilst lack time, interest or confidence and low self-efficacy reduced adherence. Within the treatment related construct, several strategies such as individualising the intervention, including goal setting, providing patient education, could increase adherence. Time was the most common barrier to physiotherapists implementing strategies to improve adherence. Conclusions: This thesis has provided data that adherence to prescribed exercise in people with SpA can be variable, often low and reduces over the course of interventions. This thesis has identified multiple interacting factors within the five constructs suggested by the WHO adherence model which may influence adherence. When prescribing exercise, physiotherapists should consider which factors are potentially affecting adherence within each WHO domain and address key modifiable factors in order to optimise adherence for that individual. Further research is required to compare rates of adherence across different modes of programmes, identifying which factors are most important in influencing adherence on a group level. Finally improving and standardising the measurement of adherence is crucial to facilitate progress and comparisons in this field.