168 Chapter 8 observed effectiveness of an intervention is directly influenced by adherence. In other words, adherent patients would show better clinical outcomes than non-adherent patients. However, our study did not reveal any associations between adherence to HBE and clinical outcomes in patients with LBP and we found that adherence to HBE recommendations varies greatly among patients and over time within the same patient (chapters 6 and 7). Interestingly, despite existing literature suggesting a more pronounced benefit of exercise interventions in patients with chronic LBP, our findings do not support this, even though patients with chronic LBP were well represented in our study (44% of our participants) (11). It appears that the relationship between adherence to exercise recommendations and recovery in patients with LBP is not as straightforward as we previously assumed and unknown factors combined with individual variation are important determinants of adherence. Therefore, before drawing definitive conclusions about the effectiveness of exercise interventions for the management of LBP, it is important to develop a nuanced understanding of adherence and its relationship with clinical outcomes. Understanding exercise adherence through medication adherence models Building upon this need for a more nuanced understanding of adherence, it is noteworthy that in the field of pharmacology, the complexity of adherence behavior has already been a significant focus of study for decades (13). This has led the World Health Organization to identify five domains of adherence to medicine (14). These domains include patientrelated factors, medication-related factors, condition-related factors, healthcare system/healthcare provider-related factors, and socioeconomic factors. This model was subsequently expanded into an adaptable conceptual framework for understanding the factors contributing to medication adherence (figure 1) (14,15). In applying this refined model to a diverse array of patient groups, the authors identified common factors. Across these groups, patient-related factors, particularly cognitive and psychological aspects like beliefs, perceptions, and concerns, were most commonly cited (15). Although no rationale was given for these common factors, the authors do provide insights in the rationales for each individual patient group. The common trend appears to be that patients weigh perceived benefits of the medication (symptomatic relief, prevention of symptoms/disease, prevention of disease progression) and their concerns (potential side effects, tolerability of side effects) in the decision to adhere to the prescribed regimen or not. These perceptions are in turn influenced by the healthcare provider through information and counselling, underscoring the importance of the role of the healthcare provider regarding patient adherence behavior.
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