Rehabilitation adherence is an outcome of a complex interaction of physical, social, therapeutic and psychological elements. This second article, based on the findings of my doctoral research, highlights the role of social support and other social influences as a determinant of rehabilitation adherence.
In a previous article, I had discussed the relationship between of rehabilitation adherence and therapeutic relationship in Do they trust you enough? The role of therapeutic relationship in rehabilitation adherence.
During the last 30 years, researchers have shown great interest in the phenomena of social support, particularly in the context of health. Social support has been described as “support accessible to an individual through social ties to other individuals, groups, and the larger community. It has also been described as “a network of family, friends, neighbors, and community members that is available in times of need to give psychological, physical, and financial help”. Theoretical models of social support specify the following two important dimensions: (1) a structural dimension, which includes network size and frequency of social interactions, and (2) a functional dimension with emotional (such as receiving love and empathy) and instrumental (practical help such as gifts of money or assistance with child care) components.
For the purpose of my research, social support included both the structural elements (e.g. did the patient have any family or friend who could provide support if required or the level of social obligations) and functional element (e.g. the level of positive reinforcement or feedback available or does the patient have anyone to provide financial support if required). The findings from my mixed methods research indicated that greater social support had a Grade II evidence of a positive relationship with attendance and Grade I evidence of positive relationship with home exercise adherence.
My research project included an initial mixed methods synthesis of qualitative and quantitative studies exploring determinants of attendance, in-clinic adherence and home exercise adherence in outpatient musculoskeletal physiotherapy clinics. This was followed by a prospective cohort study and then a qualitative study incorporating focus groups and interviews with patients, reception staff, physiotherapists and clinical managers to discuss and elaborate upon the findings. Finally, a triangulation protocol was used to combine the findings from the previous three stages to develop conceptual models and levels of evidence tables for each of the 136 determinants explored.
Patients and physiotherapists both concurred that a conflict with a patient’s regular schedule and commitments was one of the most important factors which influence their decision to not attend an appointment. These obligations included inability to take time off work, needing to care for family members and children, or other social commitments.
Participants felt that they had to prioritise their activities and sometimes attending physiotherapy did not seem important enough when weighed against other obligations.
“physiotherapy is time consuming and that patients need to alter their daily routine or take time off from work, family or social obligations to attend the department for treatment which may be difficult for some patients” (Second order)(Marwaha, Horabin and McLean 2010)
Society perceives time as a commodity and prioritising time for rehabilitation and exercises is one of the main considerations in achieving adherence to the exercise program. Willingness and ability to accommodate exercises into their daily routine, developing fixed times for exercises and being disciplined, greater level of organisational ability if the time is limited were considered to be possible facilitators of exercise adherence. Exercises which can be completed as a part of recreational activities or other activities of daily routine may promote adherence. The physiotherapists should also respect the schedule of patients when planning exercises.
“ . .. So I’ve been setting time limits, as you stated [name], in my daily planner about when to make it a priority, when I can put it in, trying to work my life around it.”(patient, first order) (Wilcox et al. 2006)
In itself, social obligations may appear to be an unmodifiable determinant of adherence. However, my research has demonstrated that a) if the perceived need is high, and b) the exercise programme is patient-centred i.e. takes into account their social obligations and exercises can be fit into the daily routine of the patient, then patients are more willing to prioritise their physiotherapy program over their social obligations and adhere with exercise recommendations. Thus a discussion between the physiotherapist and patient at an early stage to identify the interests of patients, short and long term goals and tailoring of the intervention to attain those goals may facilitate prioritisation of their physiotherapy program over their social obligations. An example of such intervention is the Brief Advice which is being provided as a part of Scotland’s new physical activity pathway. Brief Advice consists of a short (~3 minute), structured conversation with the patient aimed at raising awareness of the benefits of physical activity, exploring barriers and identifying some solutions. Similar approach may be developed and tested for therapeutic exercise as well.
Frequency of sessions, duration and number of exercises need to be optimised to ensure that patients can stay motivated by results, are able to adapt exercises into their daily routine and thus overcome the barrier of managing exercises while they still fulfil their social obligations.
Support from family, friends, peers and exercise partners
Many patients are dependent on the material, emotional and practical support from their family members. Encouragement from family members and friends provides a stimulus to continue with the exercise program. External cues and reminders to exercise along with an acknowledgement of the patients’ physical limitations, facilitates adherence to the exercise program. A lack of such support acts as a barrier to the continued engagement of participants with the rehabilitation process.
“Oh, the support I got from my family and friends was great. My husband has been fantastic watching over me making sure I don’t do anything I shouldn’t. My best friend sometimes came to the rehab centre with me which I really appreciated” (Carol, first order) (Levy et al. 2009)
Beyond the immediate family and friends, patients also enhance their support structure further by forging relationships with their peers or exercise partners. Having an exercise partner with similar abilities allowed them to share their anxieties and goals and discuss disease related issues. Apart from sharing information, it also provided social benefits of companionship while exercising, thus making it more enjoyable and acceptable.
Exercising in groups also facilitated competition and drive in some participants who wanted to do better than their peers. Patients also tend to be motivated by hearing the success stories from other patients who have undergone similar treatment.
“I meet a lot of different people … and it’s amazing how quick you can form a relationship with people that you have never met before. And it’s a great way to share time with other friends.”(patient, first order) (Wilcox et al. 2006)
Support provided by coaches in the form of understanding the athletes’ injury, recovery and rehabilitation process was considered vital to their engagement in exercise programs. If a coach considered the recommendations of physiotherapist to be worthless, then there was little chance of the athlete’s continued participation.
Conversely, if the coach was also included as a part of the multidisciplinary team who understood and encouraged rehabilitation, this promoted adherence to rehabilitation. The coaches’ understanding, approval and support for the treatment program recommended by the therapists’ was considered to be an important factor in whether athletes adhered to their exercise regimen.
“Sometimes you will get a coach who will come in with the athlete and that’s fantastic because you can discuss everything with the coach and athlete and get agreement on what he can do. Its good to have coach on your side and to work as a team.” (Physiotherapist, first order) (Niven 2007)
It has also been shown that providing social support to others may result in health benefits to the individual providing support as well. Peer support among patients with the same chronic health problem combines the benefits of both receiving and providing social support. Previous research indicates that peer support may lead to improved adherence for medication diet, and exercise.
The success of peer support appears to be due in part to the non-hierarchical, reciprocal relationship created through the sharing of similar experiences with others undergoing the same medical and/or behavioural tasks and challenges. Physiotherapy departments should consider promoting such peer support or ‘buddy’ systems to facilitate support amongst patients and thereby facilitate HEA.
Personal health beliefs and cultural exercising norms of patients are also strongly influenced by their family and friends (Sher et al. 2014). Physiotherapists should therefore endeavour to identify the important people in patient’s life, examine their role in patient’s beliefs and attitudes and evaluate their extent of support for maintaining patient’s HEA (Lanoutte et al. 2009). This may also facilitate a discussion about a patient’s social obligations, priorities and consequent need for prioritising HEP within the daily routine.
There may be occasions where despite best intentions, a patient may not be able to attend the appointment due to social obligations or other urgent priorities. In such situations, it may be useful to provide more accessible rescheduling and cancellation procedures which may include use of text messages or emails, online calendars or social media websites such as Facebook or Twitter. Promoting cancellation of appointments within a timeframe which allows physiotherapy departments to re-allocate the appointments may be useful to ensure appropriate utilisation of resources.
Recent evidence has suggested that while there is recognition of contribution of the psychosocial elements to a patient’s experience, it is not regularly addressed by the physiotherapists in clinical practice. This has been attributed to lack of adequate training of the psychosocial issues within entry level as well as post qualifying programs (Foster and DeLitto 2011) as well as following the traditional biomedical model of care in clinical practice, which then influences their clinical reasoning and decision making as well as the explanations provided to the patient. Foster and DeLitto (2011) have suggested several strategies which can be utilised within the entry level programs to facilitate greater focus on the psychosocial elements within physiotherapy practice including a specific focus on integrated biopsychosocial models within entry level education and greater inter-professional education.
The findings regarding the impact of social support on rehabilitation adherence from my study have emphasised the need for physiotherapists to be cognisant of and work within the bio-psychosocial paradigm and consider not only the patient and their presenting problem, but also the social environment within which they live and function to ensure that the rehabilitation programs are designed with their social obligations in mind, additional support, encouragement and education is provided to patients and their significant social influencers to facilitate adherence to the exercise programs.
Acknowledgement: The above article is based on the findings of my PhD study titled ‘Determinants of Rehabilitation Adherence in musculoskeletal physiotherapy: a mixed methods project’ funded by Sheffield Hallam University, United Kingdom (2011-2015)