Our Parting Gift

To all of our dedicated followers, we would like to sincerely thank you for following our journey to promote a sustainable and meaningful exercise rehabilitation class within physiotherapy practices today. We hope we have provided you all with the knowledge and inspiration to proactively promote a meaningful change to your practices and/or lifestyles. To conclude, we would like to provide you with a summary of our suggested solutions that were discussed over the series of blogs, presented in the form of a checklist for patients and/or physiotherapists to refer to early on; during an initial consultation of a patient eligible for exercise rehabilitation. We strongly advocate for the use of this tool in both research and clinical practice with the hope of it becoming not only a reliable, valid and responsive tool; but the gold-standard psychosocial tool used within physiotherapy rehabilitation practices around the world.

– AD, BH, JH, RJ

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Access

If there was an option between attending a group class that was one or two blocks away from your home versus a class that requires you to get dressed, get into your car, maybe make a stop to fill up your empty petrol tank and then try to find parking in a busy hospital carpark, there is no doubt that the latter option will be less popular amongst all individuals alike. There is strong evidence supporting the benefits of rehabilitation programs worldwide such as pulmonary rehabilitation, however it is estimated that <5% of eligible people actually receive any form of treatment (Cox, Oliveira, Lahham & Holland, 2017). This low rate of delivery is partly due to limited availability and access to rehabilitation services (Cox et al., 2017). In addition to patient specific barriers, there are also barriers to access within the systems level as well; with lack of access to environmental and physical resources to run these programs, reduced availability of qualified staff, and reduced advocacy for exercise rehabilitation, with these factors being exacerbated in rural settings (Johnston, Maxwell & Alison, 2015).

Suggested facilitators include providing education and training to all healthcare professionals that are experts in the particular field e.g. Cardiovascular disease. This will help to increase confidence when advocating to patients regarding the benefits of rehabilitation whether you are a physiotherapist, a speech pathologist, a doctor, or a nurse. Interdisciplinary education is an effective means of not only leading successful change (Sander et al., 2016) but engaging patients; one of the aspects of the health LEADS model. It requires health professionals from all disciplines to align with, believe in and be engaged in what they are promoting; the benefits of rehabilitation.


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As access to rehabilitation is influenced by the complex interplay between individuals, the environment and social expectations, the health LEADS model identifies that it is important to use a systems thinking approach in an attempt to try and build relationships and engage with all stakeholders involved in the field of exercise rehabilitation (Health Workforce Australia, 2013). Therefore, there is a need to reach out to patients, the government health care sector, health professionals, and even the transport industry in an attempt to address all the aforementioned barriers. Focus groups should be encouraged and should call upon a randomised sample of individuals requiring rehabilitation, representatives from government bodies, and a few health care professionals. This will aim to create an alliance between all stakeholders in an attempt to create a shared vision to work towards. This will be beneficial for the government in particular as it will help re-direct the budget towards areas that are meaningful to everybody involved in the rehabilitative setting, whether it focuses on providing half price taxi vouchers to patients, providing  professional development sessions for healthcare professionals, or whether they set up a second-hand equipment shop to access pulse oximeters, blood pressure cuffs and gym equipment required for rehabilitation.

Therefore the need for a focus group cannot be emphasised enough as it will no doubt provide a tangible solution (a.k.a. Redirection of funding) for such a tangible barrier!

 – AD

References:

Cox, N. S., Oliveira, C. C., Lahham, A., & Holland, A. E. (2017). Pulmonary rehabilitation referral and participation are commonly influenced by environment, knowledge, and beliefs about consequences: a systematic review using the Theoretical Domains Framework. Journal of Physiotherapy, 63(2), 84-93.

Health Workforce Australia (2013, July). Health LEADS Australia: the Australian Health Leadership Framework. Retrieved from https://www.aims.org.au/documents/item/352

Johnston, C. L., Maxwell, L. J., & Alison, J. A. (2015). Establishing and delivering pulmonary rehabilitation in rural and remote settings: The opinions, attitudes and concerns of health care professionals. Australian Journal of Rural Health.

Sander, O., Schmidt, R., Rehkämper, G., Lögters, T., Zilkens, C., & Schneider, M. (2016). Interprofessional education as part of becoming a doctor or physiotherapist in a competency-based curriculum. GMS journal for medical education, 33(2).

Social Support

Jack et al. (2010) has found in his systematic review that low levels of family or social support are barriers to patients’ adherence. This finding is further supported by another review (Conraads et al., 2012), which concludes that inadequate social support would lead to a feeling of isolation, and reduce one’s motivation to follow prescribed treatments. This review also suggests that other social factors, such as being divorced, living alone, and having less support to be brought to facilities, negatively influence one’s access to health services, which would in turn, reduce one’s adherence to treatments.

Many simple and effective strategies can help to increase social support and improve one’s adherence to rehabilitation. Social support could come from families, friends, neighbors, co-workers, or community members. Seeing peers attending and adhering exercises has been shown to improve one’s self-efficacy to follow treatment plans (Tierney et al., 2012). Involving partners in the rehabilitation may also help to increase the patient’s motivation (Fekete et al., 2006). A key facilitator to improve social support is to engage patients’ families and friends. Health LEADS Australia (HLA) suggests that it is a clinician’s responsibility to create a positive and engaging environment for people to participate in. One of the hallmarks of great leaders is the ability to communicate and develop strong beliefs (Giuliani, 2002). Clinicians should try to excite people with their vision, bring people aboard and earn their support.

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To create a truly engaging environment, clinicians need to understand each patient’s different health journey and needs (Baron, 2009). Leaders are sometimes followers, and effective leaders know how to follow (Northouse, 2011). This concept indicates that leaders should motivate and attract people through identifying and customising to each client’s different life circumstances. Therefore, clinicians should work collaboratively with patients and carers to identify their needs and plan treatments that best suit their availability.

Leadership is more than a set of skills, and relies on multiple subtle personal qualities, such as humility, and enthusiasm (Northouse, 2011). A review by Vahdat et al. (2014) finds that limitations of health professionals themselves including a lack of cultural awareness and communication skills, can inhibit the creation of an engaging environment. Therefore, health leaders should self-reflect and seek strategies to address their limitations. This allies with the focus of ‘leads self’ in the HLA (Health Workforce Australia, 2013). Great clinicians have to undergo a process of personal understanding and self-discovery to find their weakness and improve accordingly (Rooke & Torbert, 2005).


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Moreover, a change of health systems may be required, such as increasing funding for transportation support if a lack of social support to get to the facilities is the key barrier. While the aim of HLA is to build a people focused health system that is effective and equitable for both patients and clinicians, the lack of social support and inequity in accessing health services needs to be addressed (Sebastian et al., 2013).

 – JH

References:

Baron, S. (2009). Evaluating the patient journey approach to ensure health care is centred on patients. Nursing times, 105(22), 20-23.

Fekete, E. M., Stephens, M. A. P., Druley, J. A., & Greene, K. A. (2006). Effects of spousal control and support on older adults’ recovery from knee surgery. Journal of Family Psychology, 20(2), 302.

Giuliani, R. W. (2002). with Ken Kurson. Leadership.

Jack, K., McLean, S. M., Moffett, J. K., & Gardiner, E. (2010). Barriers to treatment adherence in physiotherapy outpatient clinics: a systematic review. Manual therapy, 15(3), 220-228.

Northouse, P. G. (2011). Introduction to leadership: Concepts and practice. Sage.

Rooke, D., & Torbert, W. R. (2005). Seven transformations of leadership. harvard business review, 83(4), 66-76.

Sebastian, A., Fulop, L., Dadich, A., Fitzgerald, A., Kippist, L., & Smyth, A. (2014). Health LEADS Australia and implications for medical leadership. Leadership in Health Services, 27(4), 355-370.

Tierney, S., Mamas, M., Woods, S., Rutter, M. K., Gibson, M., Neyses, L., & Deaton, C. (2012). What strategies are effective for exercise adherence in heart failure? A systematic review of controlled studies. Heart failure reviews, 17(1), 107-115.

Vahdat, S., Hamzehgardeshi, L., Hessam, S., & Hamzehgardeshi, Z. (2014). Patient involvement in health care decision making: a review. Iranian Red Crescent Medical Journal, 16(1).

Making Time

‘A lack of time’ has long been identified as a key barrier to treatments in an early prospective study (Alexandre et al., 2002). In this study, barriers, such as busy working schedules, a lack of time, needs for child care, financial constraints are found to associate with poor  patients’ adherence. These barriers are personal and individualised. In general, male patients tend to report busy working schedules and laziness being their main barriers to rehabilitation, whereas the female patients are more likely to quit a program due to family obligations and their commitments to family, work and community activities.

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While a number of personal barriers can inhibit patients’ participation in rehabilitation, many of these are predictable. It is described by Giuliani (2002) that a good leader is able to identify potential problems and prepare relentlessly before barriers happen. In order to do this, clinicians need to first appreciate patients’ diverse values and cultural responsiveness. All patients’ perspective and conditions should be treated with respect. As reasons for non-adherence are individualised and multi-factorial, a patient’s individual preferences and social characteristics, such as working schedules and family situations, should be considered by clinicians during treatment planning to maximise one’s possible participation (Jones et al., 2007).

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Leadership is a people activity and is much more complex than planning activities. This is to say, after planning, leaders should engage followers to actively involve in the pursuit of shared plans. To do this, the Health LEADS Australia (HLA) model encourages leaders to engage others with the use of explanations and encouragements (Health Workforce Australia, 2013). One-to-one meetings and cognitive-behavioral training, such as motivational interviews, can be used to optimise the communicative process and reduce one’s perception of barriers (Gohner & Schlicht, 2006). It is also proved in a systematic review by Tierney et al. (2012) that cognitive behavioral strategies, such as education about problem-solving skills and motivational interviews can improve patients’ confidence in continuing exercise programs. Improved self-efficacy could also positively influence patients’ persistence and willingness to engage in a program. The ultimate goal of engaging patients is for each person to take responsibility to follow the plan and achieve the desired outcome.

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Also, is it about having time or making time for rehabilitation? Setting appropriate goals can improve one’s self-management skills and long-term adherence to treatment (Pozehl et al., 2014). Rost (1993) argues that leaders and followers should keep an independent relationship and collaborate together towards shared goals. An important aspect of this is that leaders should influence followers to share a common vision with them. This idea of setting goals and implement goal-oriented plans aligns with another key focus of ‘achieves outcomes’ in the HLA. Planning how, when and where a plan can be implemented will increase the chance of performance of an intended behavior (Gollwitzer, 1999). Therefore, for patients, especially those who drop out due to their busy schedule, clinicians should set realistic and motivating goals together with them to determine how rehabilitation programs could fit into their lives.

– JH

References:

Alexandre, N. M. C., Nordin, M., Hiebert, R., & Campello, M. (2002). Predictors of compliance with short-term treatment among patients with back pain. Revista Panamericana de Salud Pública, 12(2), 86-95.

Conraads, V. M., Deaton, C., Piotrowicz, E., Santaularia, N., Tierney, S., Piepoli, M. F., & Jaarsma, T. (2012). Adherence of heart failure patients to exercise: barriers and possible solutions. European journal of heart failure, 14(5), 451-458.

Giuliani, R. W. (2002). with Ken Kurson. Leadership.

Gohner, W., & Schlicht, W. (2006). Preventing chronic back pain: evaluation of a theory-based cognitive-behavioural training programme for patients with subacute back pain. Patient education and counseling, 64(1), 87-95.

Health Workforce Australia (2013, July). Health LEADS Australia: the Australian Health Leadership Framework. Retrieved from https://www.aims.org.au/documents/item/352

Gollwitzer, P. M. (1999). Implementation intentions: Strong effects of simple plans. American psychologist, 54(7), 493.

Jones, M., Jolly, K., Raftery, J., Lip, G. Y., & Greenfield, S. (2007). ‘DNA’ may not mean ‘did not participate’: a qualitative study of reasons for non-adherence at home-and centre-based cardiac rehabilitation. Family practice, 24(4), 343-357.

Pozehl, B. J., Duncan, K., Hertzog, M., McGuire, R., Norman, J. F., Artinian, N. T., & Keteyian, S. J. (2014). Study of adherence to exercise in heart failure: the HEART camp trial protocol. BMC cardiovascular disorders, 14(1), 172.

Rost, J. C. (1993). Leadership for the twenty-first century. Greenwood Publishing Group.

Comorbidities and Premorbid Health

Following a hospital stay, a lower premorbid level of health generally means the outcomes will be worse off, simply because the patient is starting at a functional level that is lower than average. Consequently, these people as well as those with multimorbidities can struggle in programs designed specifically for just one chronic condition as they have more issues impacting physical performance (Smith et al. 2012). Compliance with exercise is understandably difficult when there are a multitude of other health issues to keep in mind, so when noting the effects of the patient’s medications and prescribing exercise, carefully consider each individual’s specific needs based on how they present and what they feel they would need to adhere to any treatments.

Exercise has been shown to be beneficial for people with multimorbidities across a plethora of conditions (Zgibor et al. 2016) and specific interventions that target functional impairment, which exercise can provide, could also be effective in managing people with multimorbidities (Smith et al. 2012). It is crucial therefore that patients continue healthy exercise behaviour within the boundaries of their health status to maintain functional capacity and quality of life.

People living with multimorbidities tend to draw on their past experiences of exercise and their perceptions and beliefs around health to guide their current exercise behaviour (Simonik et al. 2016). Using leadership principles to help shape these beliefs and experiences into something that will empower the patient and facilitate their progress towards an independent, compliant exercise routine would be beneficial to improving and/or maintaining function. Given a functional goal approach to exercise is best for patients with multimorbidities, exercise programs, like their health status, will be very individualised. It is up to the clinician then to show the client what they could be achieving and then engage them with collaborative goal setting and collaborative exercise prescription in a manner that avoids any barriers to exercise, such as how best to manage any symptoms like pain during exercise (which is normal, just not too much pain), to ensure that these patients have the best outcomes.

Looking at a wider scope of health practise, the current health system favours a biomedical approach due to the time constraints within clinical settings. It is undoubtedly effective when multiple conditions are present, but taking the extra step to a biopsychosocial approach can reap even more rewards for the patient. On top of that, spending the extra time at the beginning to consider the psychosocial factors of each multimorbidity patient, such as their barriers and facilitators to treatments and becoming more of a case manager for them (Smith et al. 2016), would end up saving time in the long run as it considers the method with the greatest chance of improving health, rather than applying a “one shoe fits all” method of exercise prescription and then scratching heads when the client discontinues their program later on. Explore avenues to shape the system of whatever setting you work in, or if you’re the patient, be active and engaged, make sure they ask you what works best for you!

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– RJ

References:

Simonik, A., Vader, K., Ellis, D., Kesbian, D., Leung, P., Jachyra, P., Carusone, S. C., & O’Brien, K. K. (2016). Are you ready? Exploring readiness to engage in exercise among people living with HIV and multimorbidity in Toronto, Canada: a qualitative study. BMJ open, 6(3), e010029.

Smith, S. M., Soubhi, H., Fortin, M., Hudon, C., & O’Dowd, T. (2012). Managing patients with multimorbidity: systematic review of interventions in primary care and community settings. Bmj, 345, e5205.

Zgibor, J. C., Ye, L., Boudreau, R. M., Conroy, M. B., Vander Bilt, J., Rodgers, E. A., Schlenk, E. A., Jacob, M. E., Brandenstein, J., Albert, S. M., & Newman, A. B. (2016). Community-Based Healthy Aging Interventions for Older Adults with Arthritis and Multimorbidity. Journal of Community Health, 1-10.

Self-Efficacy

A large number of people do not resume normal functioning during the early recovery period after an inpatient stay; in fact, they experience a decline in function. After a myocardial infarction, it has been found that most patients decline during the first month after discharge, which consequently increases the risk of one-year mortality and risk of  readmission due to either further cardiac events, or secondary sequelae such as depression (Vibulchai, Thanasilp & Preechawong, 2015). There has been extensive literature that supports the benefits of rehabilitation, however the majority of it has focused on the physical rather than the psychological well-being of patients (Lavie et al., 2015). Furthermore, the literature commonly identifies benefits in the short term, with limited benefits shown in the long term. This all leads to the hypothesis that exercise programs currently do not achieve effective behavioural change in patients and that rehabilitation should take on a multidimensional approach which will account for psychosocial factors including self-efficacy, which has been shown to be important predictors of functional status (O’Neil et al., 2013).

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Self-efficacy refers to the beliefs in one’s capabilities to execute an action. According to Bandura’s social cognitive theory, if people lack self-efficacy, they will likely perform an action ineffectively even if they know how to do it. One way to tackle this problem is to use skills mastery (Bandura, 1997); a method in which patients master fair and achievable goals. Bandura’s theory has proven to be successful in improving a patient’s psychological and functional status across multiple settings, including exercise rehabilitation (Vibulchai, Thanasilp & Preechawong, 2015) .

Failures are problematic, particularly if they happen early. This is important in terms of functional rehabilitation and goal setting; if we choose an overly ambitious goal and the patient fails, Bandura explains that this will negatively affect self-efficacy and thus, the patient may be deterred from returning to or completing rehabilitation. If we surveyed 100 practicing physiotherapists out there, I can almost say with confidence that 90 of you approach goal setting with a sole biomedical point of view; a goal that will aim to achieve what you as a therapist wants. However, what most of you do not realise is that compliance is a huge issue as these goals may not align with the patient’s needs. Health Leads Australia highlights the importance of collaboration when it comes to achieving outcomes (Health workforce Australia, 2016). This could simply be the case of integrating exercises into patient hobbies. Furthermore, a systems based thinking approach is required, and so involvement of all stakeholders is beneficial; for example, if the patient requiring rehabilitation is a professional golfer, involve their golf coach when designing their exercise program. This may be as easy as making a phone call to the coach to find out what exactly the patient does. Finally, it is important to consider the possibility of a patient regressing, therefore ensure goal setting is well paced and each goal is carefully thought out and achievable, as this will help patients build a sense of confidence in order to move on.

For any  patients out there who are reading this blog, I encourage you to stand your ground and tell your therapist what you really think! Don’t be afraid to have your say, collaborate, rise to the top  and achieve your outcomes!

– AD

References

Bandura A. Self-Efficacy: The Exercise of Control. New York: Freeman, 1997.

Health Workforce Australia (2013, July). Health LEADS Australia: the Australian Health Leadership Framework. Retrieved from https://www.aims.org.au/documents/item/352

Lavie, C. J., Arena, R., Swift, D. L., Johannsen, N. M., Sui, X., Lee, D., …& Blair, S. N. (2015). Exercise and the Cardiovascular System: Clinical Science and Cardiovascular Outcomes. Circulation Respiratory, 117(2): 207–219    

O’Neil A, Berk M, Davis J, Stafford L. Cardiac-self efficacy predicts adverse outcomes in coronary artery disease (CAD) patients. Health Educ. Behav. 2013; 5: 6–14.

Vibulchai, N., Thanasilp, S., & Preechawong, S. (2015). Randomized controlled trial of a self‐efficacy enhancement program for the cardiac rehabilitation of Thai patients with myocardial infarction. Nursing & health sciences.

Health Literacy

Health literacy is basically how much a person is able to find and understand health information or concepts and use the health system. Turns out despite what certain celebrity chefs would have you think, health is a complex topic and not everyone gets it. Someone with a lower level of education, lower socioeconomic status, who lives in less populated areas, or has advanced age can predispose them to having inadequate health literacy (van der Heide et al. 2013; Lee et al. 2010; Howard et al. 2006) which is linked to poorer health outcomes (Bennett et al. 2009; Berkman et al. 2011; Lee et al. 2010; van der Heide et al. 2013). Only 43% of Australians have adequate health literacy (Australian Bureau of Statistics, 2006). Where do you think you sit?

It’s important to note that exercise and understanding the need to exercise is something health literacy affects. For rehabilitation following a hospital stay, if a client does not understand the relevance of the exercise they are prescribed, they will be less likely to continue with their rehabilitation (Norman, 1998). If a client chooses to discontinue their exercises then they are obviously less likely to make a full recovery, but they are also less likely to partake in independent exercise at a level high enough to be beneficial for them (Carlson et al. 2000; Daltroy, 1985). This compliance issue has existed for decades and is still considered to be a major challenge in the rehabilitation and maintenance space of physiotherapy.

It has been shown that for the elderly population, beliefs about exercise and its benefits can be major factors affecting their adherence to an exercise program (Resnick & Spellbring, 2000) and this falls under a health literacy space. To prevent low health literacy from being a factor ruining exercise compliance, the patient needs to improve their knowledge of their condition, learn how best to manage it, and then learn how to manage it themselves (Gold & McClung, 2006). Guiding the patient through that process will teach them what to do to attain their highest possible quality of life but also what to do when they have a bad day and symptoms increase. This also boosts patient self-efficacy, which determines how confident someone feels they are when managing their health. Low self-efficacy has been shown to be a major contributing factor to non-compliance (Chen et al. 1999), but health professionals are in a great position to address this.

You ready for the plug? You could use a Health LEADS approach to improve health literacy and hence exercise compliance. Collaborative goal setting is a way the clinician can negotiate around barriers and beliefs and set targets with the client, giving them a stake in their own treatment prescription, and thus engaging them. These goals must be relevant to the client and it has been shown that when the patient is involved in goal setting, they are more compliant to an exercise program (Bassett & Petrie, 1999), particularly group/team programs (Nielsen et al. 2014). Taking a goal directed approach also improves the patient’s ability to achieve their outcomes, another key element of Health LEADS. Encouraging self-management is another good option for ensuring long-term adherence to healthy behaviours (Lorig et al. 2001; Gold & McClung, 2006). Getting involved in a self-management program (if applicable) presents the client to a group of similar individuals and a peer successfully managing life with the condition which can all be used as proof of achievable outcomes through adherence to the treatment plan. You just have to know what’s out there.

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– RJ

References:

Australian Bureau of Statistics (2006). 4233.0 – Health Literacy, Australia, 2006. Retrieved from: http://abs.gov.au/AUSSTATS/abs@.nsf/Latestproducts/4233.0Main%20Features22006?opendocument&tabname=Summary&prodno=4233.0&issue=2006&num=&view=

Bassett, S. F., & Petrie, K. J. (1999). The effect of treatment goals on patient compliance with physiotherapy exercise programmes. Physiotherapy, 85(3), 130-137.

Bennett, I. M., Chen, J., Soroui, J. S., & White, S. (2009). The contribution of health literacy to disparities in self-rated health status and preventive health behaviors in older adults. The Annals of Family Medicine, 7(3), 204-211.

Berkman, N. D., Sheridan, S. L., Donahue, K. E., Halpern, D. J., & Crotty, K. (2011). Low health literacy and health outcomes: an updated systematic review. Annals of internal medicine, 155(2), 97-107.

Carlson, J. J., Johnson, J. A., Franklin, B. A., & VanderLaan, R. L. (2000). Program participation, exercise adherence, cardiovascular outcomes, and program cost of traditional versus modified cardiac rehabilitation. The American journal of cardiology, 86(1), 17-23.

Chen, C. Y., Neufeld, P. S., Feely, C. A., & Skinner, C. S. (1999). Factors influencing compliance with home exercise programs among patients with upper-extremity impairment. American Journal of Occupational Therapy, 53(2), 171-180.

Daltroy, L. H. (1985). Improving cardiac patient adherence to exercise regimens. Journal of Cardiac Rehabilitation, 5(1), 40.

Howard, D. H., Sentell, T., & Gazmararian, J. A. (2006). Impact of health literacy on socioeconomic and racial differences in health in an elderly population. Journal of general internal medicine, 21(8), 857-861.

Lee, S. Y. D., Tsai, T. I., Tsai, Y. W., & Kuo, K. N. (2010). Health literacy, health status, and healthcare utilization of Taiwanese adults: results from a national survey. BMC public health, 10(1), 614.

Lorig, K. R., Sobel, D. S., Ritter, P. L., Laurent, D., & Hobbs, M. (2000). Effect of a self-management program on patients with chronic disease. Effective clinical practice: ECP, 4(6), 256-262.

Nielsen, G., Wikman, J. M., Jensen, C. J., Schmidt, J. F., Gliemann, L., & Andersen, T. R. (2014). Health promotion: The impact of beliefs of health benefits, social relations and enjoyment on exercise continuation. Scandinavian journal of medicine & science in sports, 24(S1), 66-75.

Norman, K. V. (1998). Motivation and compliance in exercise programs for older adults. Journal of Physical Education, Recreation & Dance, 69(8), 24-27.

Resnick, B., & Spellbring, A. M. (2000). Understanding what motivates older adults to exercise. Journal of gerontological nursing, 26(3), 34-42.

van der Heide, I., Wang, J., Droomers, M., Spreeuwenberg, P., Rademakers, J., & Uiters, E. (2013). The relationship between health, education, and health literacy: results from the Dutch Adult Literacy and Life Skills Survey. Journal of health communication, 18(sup1), 172-184.