Adherence a complex and multifaceted construct and

Adherence to different kinds of literature has different meanings (1).

In the health professionals literature use the concept of Adherence as synonymous with the concept of Compliance, however, the nature of the compulsory of the Compliance has been criticized (2). Some researchers believe that Adherence is a complex and multifaceted construct and is challenging for the patient (1, 2). Patient Adherence to therapeutic regimens is the area in which individuals follow the prescribed treatment orders and also the extent to which the person’s actions or behavior are consistent with recommendations or therapeutic guidelines for preventing, controlling, or correcting their impairments (2, 3). According to the definition of the World Health Organization, Adherence is the area in which individual behaviors, receiving medication, following a diet or changing lifestyle are in accordance with the recommendations of health care providers (4) In Adherence to the treatment regimens, The patients participate in the regimen when they agree with it (5). Despite the agreement on the importance of the phenomenon of adherence to health care, there is still no clear definition of this concept and there is no agreement within or among disciplines regarding the conceptual definition of Adherence (1, 2). The existence of the same definition of the concept of adherence is very important in the process of treating chronic diseases such as stroke (2).Stroke is after heart disease, cancer, chronic respiratory disease, unwanted injuries and falls, and despite the interventions done in the acute phase, which has reduced the mortality rate, it has caused many disabilities in the world and the United States (8).

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Because of these problems , Adherence to long-term treatments, especially rehabilitation, is a major issue in healthcare provision. Studies show that only 50% of people with chronic diseases in developing countries follow the recommended regimens (2). Adherence to drug therapy is usually less than 50% and for rehabilitation treatments, it reaches even less than 50% (9). According to the results of studies, adherence to chronic situations is lesser than acute situations, so, unfortunately, patients abandon their treatment plans after 6 months of treatment. Given that stroke rehabilitation in a hospital begins immediately after diagnosis to prevent life-threatening problems in patients (10) And these patients face a variety of physical, emotional, cognitive, mental, psychosocial and social problems that disrupt their daily activities (1, 11),  treatment regimens for stroke patients are in various fields, including rehabilitation, diet, and medication (18).

These regimens in stroke patients are part of the therapeutic programs provided by health care providers to help patients who have been injured by their illness (13) receiving long-term rehabilitation services to reduce the disability for these patients is very necessary (12). Performing various rehabilitation programs using exercise, cognitive-behavioral therapy, patient education and attention to social supportive environments reduces the complications of chronic diseases and increases the quality of life in patients (13, 14). Studies have shown that good rehabilitation results are strongly related to high motivation and cooperation between patients and their families (14, 6).In literatures related to brain injuries, although the role of motivational factors in the process of rehabilitation has been shown (10, 15), But few studies have examined the concept of Adherence related to patient behavior (1), The results of studies conducted in Iran and other countries show Lack of awareness of care in patients with stroke and the lack of adherence to rehabilitation programs by them and their families, and Emphasizing training and planning for advancement in the patient rehabilitation (16-19).

Therefore, in order to improve adherence to treatment regimens, the first step is to fully understand the relevant concepts. There is no clear definition of Adherence that reflects the patient-centered approach and the dynamic nature of Adherence behavior and related conditions. The analysis of the concept of adherence is the first step towards understanding the widespread complications of treating different treatments in patients. Despite studies on the concept of adherence to treatment regimens (1, 2, 9),and essential role of nursing in this filed (28,29), Nursing studies have not been carried out to understand and interpret this concept. It has been suggested that further studies on the further detection of the concept of adherence to recommended and focused treatments (1).

In order to ensure that the concept is comprehensively examined, In this regard, researchers can use qualitative studies that provide good information in this area for the thorough examination of the concept (20, 21) (20.21) Therefore, since concept analysis for the development of nursing diagnosis and clinical problem solving is also necessary (22) And the issue of Adherence to rehabilitation in stroke is very important , This study was done with the purpose of analyzing the concept of adherence to the rehabilitation regimen in stroke patients by Avant-Walker method.Methods:The concept is a complex idea or complex image of a phenomenon.

An analysis of the concept is a clear and appropriate approach that the intended attributes of the concept are initially identified and the concept of the other similar concepts is distinguished (22) and the correct use of the concept considered in the real world is guaranteed (23). In this study, the 8-step walker Avant method used with regard to the purpose of the study to help clarify and reduce the ambiguity of Adherence to rehabilitation Regimen Concept in stroke patients.the eight steps of this method include (2011): Select a concept, Determine the aims or the purpose of the analysis, Identify all uses of the concept, Determine the defining attributes, Construct a Model Case, Construct the Borderline, Related, Contrary Cases? Identify Antecedents and Consequences, Define Empirical referents(24).To find relevant articles, articles from 1990 to 2017 in databases such, CINHAL, PubMed,  Scopus ? Google scholar ?Iranmedex ?Magiran  and Sid by keywords: Adherence to rehabilitation regimen, rehabilitation program, Rehabilitation guideline, Compliance, stroke patients, patients with stroke, cardiovascular disease and other related key words , ware searched. Inclusion criteria were articles in Persian and English, the existence of keywords in the title and abstract, related to the concept of adherence to the rehabilitation regime, access to the full text and ware not repetitive. All articles containing definitions, Attributes, Antecedents, and consequences of the rehabilitation regime concept were included in the study. 45 papers were selected. The quality of selected articles was evaluated using author credibility and scientific validity of the journals in which the articles were printed.

this study was approved by the Ethics Committee of the University of Welfare and Rehabilitation Sciences by code ….


…… The steps for analyzing the concept are described in more detail below.  Select a ConceptThe importance of each particular concept depends on a range of different factors in the discipline and the boundaries outside of it over time (25).

Adherence is a key concept in nursing practice and affects patient care throughout the health care system (2). In the first step, given the importance of the concept of Adherence in many health studies, there is still no definite definition of it, especially in the field of rehabilitation of chronic patients. This concept was chosen for study.

In 2007, The National Council on Patient Information and Education issued several common terms in literatures to describe patient self-care from treatment regimens in response to the recommendations of therapists. Compliance, adherence, and concordance are often used in texts. The term Compliance has been used since the 1950s and gained popularity in the 1970s. In the 1990s, researchers began to use adherence rather than Compliance. Negative implications of the concept of Compliance is associated with the patient’s lack of independence and inactivity in the process of treatment (19, 26). The concept of concordance is also found in some literatures that show more collaboration in the treatment program between the patient and the provider and is particularly popular in the European medical community. However, more compliance and Adherence are noted in studies (2).

Some authors state that the concept of Adherence reflects an active, voluntary, and participatory relationship between the patient and the health care team. (3) The concept of Adherence to rehabilitation regimen is also considered in this study, given that an important protocol for treatment of chronic patients Stroke and many challenges about it are being studied.Determine the aims or the purpose of the analysis       From the objectives of conceptual analysis, raising the exploratory power of the concept by examining the internal structures of an ambiguous concept and identifying its constituents (25), Also, the clarification of the concepts used and the distinguishing of a concept from similar concepts and develop the concept can be mentioned (27).

Since the study concluded, the same agreement has not yet been reached in defining this concept, and studies in this area have suggested further studies in this regard (1, 2), Present concept analysis aims to help clarify the concept of adherence to the rehabilitation regimen in stroke patients while trying to reduce the ambiguity and the semantic integration of this concept to increase the stability of the application of this concept in articles and topics related to the health of patients with stroke. Walker and Avant argue that depicting a general outline of the applications of the concept under evaluation enables a richer understanding of the concept and validation of the defined attributes (24, 25).Application of Concept of Adherence to Rehabilitation Regimen in Stroke PatientsIn a study by Bissonnette (2008) which used the evolutionary approach to identify and discover the concept of Adherence in all health disciplines, the results showed that in studies conducted There was no difference between the concept of Adherence and compliance. Alternative terms represent the adherence were, Concordance, agreement, cooperation, and partnership  . The most common definition was as follows: Adherence is the area, that patients follow and obey the orders they are given for prescribed treatment.

There was no definition of adherence indicating a patient-centered approach and the dynamic nature of Adherence behavior (1). In this regard, and with regard to the issues related to the adherence to treatments, attention to rehabilitation is essential as a part of the treatment plan for chronic patients, which plays a very important role in the therapeutic outcomes of patients (10,15).Rehabilitation is a collaborative goal-oriented process that involves patients, relatives of patients and health professionals over a period of time (10,50). Adherence to the rehabilitation regime means adherence to treatments and planned rehabilitation programs for patients, and has an effective role in the treatment outcome of chronic patients, including stroke, (18,30, 32).

Studies in the field of multidisciplinary rehabilitation show improvements in patients after receiving rehabilitation services as a result of adherence (10, 15).4. Determine the defining attributesThe attributes of the concept are characteristics that are repeatedly used during the discussion of the concept (25) and play an important role in distinguishing the Concept analyzed from different concepts (27).Adherence to rehabilitation regimen is, complex and multidimensional construct (35,36,30,1), dynamic behavior (1,34,38) and measurable (1,34), and challenging behavior of patient (36,1) influenced by the social context in which (1), dependent on level of disease and its complications (16, 33,35) and family-centered (38) changeable (35,36) situational (38,35), dependent on the behavior of health care providers and the outcomes of the disease (36) Voluntary, collaborative and active communication between the patient and the health care provider (3).5.Case modelThe case model or example is a pure example of the concept studied and should have all the attributes that define the concept (25).A 70 year- old man , a stroke patient  with a hemiplegia of the right side of the body, and aphasia from 9 months ago , he hopes to be treated, and follow his rehabilitation team  instructions , regarding the use of medications and speech therapy ,physiotherapy , occupational therapy and other programs that rehabilitation team setting for him.

Timely with his family attends to physiotherapy and occupational therapy and speech therapy meetings. He Performs rehabilitation exercises at home ten times in the morning, evening and night. His family Supports him and, he has hopefuls and wants to get back to work as soon as possible.

States that he has been significantly improved by exercising and following his rehabilitation regimens.border line caseIdentifying borderlines reduces ambiguity between cases by clarifying attributes that are basic for the model (25). The borderline has many attributes of the concept, but it does not all of them (24,25,27). A 75-year-old women had a history of stroke with right hemiplegia with aphasia, With his son’s help to carry out the rehabilitation process for stroke, refer to Rehabilitation Center, he was reluctant to perform the rehabilitation process, but his family were very supportive and follow his treatment programs. they do all the commands and exercises given by the rehab teams. His son says he has gone to the centers of physiotherapy, occupational therapy and speech therapies, as well as psychological counseling according to the development of his physician before being admitted to the rehabilitation center. They are very hopeful that their mother will recover and get back to her family with rehabilitation services.Contrary CasesContrary Cases does not include any of the main attributes of the concept.

Its definition indicates what the concept is not. This definition is so obvious that most people can see with certainty that this is not an example of our concept (25).A 68-year-old Man had a history of stroke 4 months ago, Paralysis of the left side of the body. he doesn’t speak with his family, his family says he understands our speaking but doesn’t to answer. According to his son’s words, he does not have the necessary cooperation. Do not pay attention to the instructions of the physician and the rehab teams. It does not show reluctance to cooperate with and observe rehabilitation programs.

Her family gives her a drug forcibly.6. AntecedentsAntecedents are events that must be revealed before the concept emerges (25). Common Antecedents for realizing the concept of adherence to the rehabilitation regimen include: the age of the patient, the number of children of patient , the level of education, insurance coverage, marriage (33) severity and complications of disease (34,33,1) attitudes , characteristics and beliefs (1, 10, 30), patient financial and social support, trust in health care providers, type of regimen, duration of adherence to the treatment regimen (1) Cognitive, emotional and social factors (9) motivation and perception, belief in the benefits of treatment, family support, nature of disease, health habits, level of awareness, social status and person’s Adaptation  and communication between Patient and therapists (35).

7.ConcequencesThe consequences are apparent after the concept emerges (25).in Overall, Adherence to rehabilitation regimen  leads to improved treatment outcomes (1, 6, 31, 34, 35), reduction of depression and complications of the disease (35), reduction of recurrence of the disease (31, 35), improvement of abilities and fitness (30 , 1) increased responsibility for improving their health (41) improving physical (33, 42) and mental performance (33). 8. Empirical referentsThe last step in analyzing the concept is defining empirical referents for the main attributes of the concept (25).

McKenna believes that empirical references, given the abstract nature of the main attributes, antecedents, and consequences of the phenomenon, can help clarify the operational concept (27). But according to Walker and Avant, if the concept is so abstract, the attributes of the concept are also abstract and thus cannot be good empirical symbols. Empirical references are recognizable attributes of the concept, whose emergence is a sign of self-concept, and the purpose of their definition is to facilitate the measurement and identification of the concept and to help the production of research tools (25, 43). In order to understand the problems in the field of Adherence, it is necessary to accurately measure it in patients (1, 15, 30). Few studies have been conducted in the field of follow-up on rehabilitation in patients (15). Most of the existing tools for adherence to the concept of medication adherence have been investigated (16,19,42,83) or, the functional impairment scales (FIM) for evaluating primary results of adherence and Instrumental Activities of Daily Living (IADL), physical functioning  of SF-36, and Stroke Impact Scale (SIS) to measure secondary outcomes Adherence to rehabilitation programs has been used. According to the study, no specific tool for measuring Adherence to different regimens in patients with stroke was found. Although many studies have pointed to the role of many factors in the process of rehabilitation of stroke patients, research on patient involvement is scattered in its recovery, partly due to the lack of reliable tools in this field.

Therefore, considering that today one of the most sensitive decisions in the studies is the selection of appropriate measuring instruments and the concept of adherence to rehabilitation is also influenced by the attitude, cultural, social, and family roles, attention to the accurate measurement of this concept and making appropriate tools for patients with brain injuries seems essential. 


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