Motivation in Pulmonary Rehabilitation.

Pulmonary rehabilitation is a highly evidenced intervention used in the management of patients with chronic obstructive pulmonary disease. Both patients and healthcare professionals have anecdotally acknowledged motivation as a key element in a programme. It has been suggested by some authors that motivation should be a prerequisite to entry, yet there is no evidence to support this suggestion. The purpose of this study therefore, was to provide some theory about the role of motivation in pulmonary rehabilitation and to produce a measurement instrument to enable further quantitative study.
Methods
A qualitative, exploratory investigation using focus groups and face-to-face interviews with patients undergoing a pulmonary rehabilitation programme was undertaken to generate data around factors influencing motivation. Results were used to develop a 43 item self-report questionnaire. The questionnaire was administered to 77 patients before and after a pulmonary rehabilitation programme along with other health status measures. The questionnaire was tested for reliability and validity. Item reduction was performed using factor analysis.
Results
Motivation within the context of a PR programme was shown to consist of a number of psychological, social and circumstantial variables that fell into 3 broad dimensions: Essential motivation, external motivation and functional outcome. A key finding was that attending pulmonary rehabilitation had an enormous positive influence on the patients’ essential motivation. The questionnaire was reduced to 21 items and principal components analysis demonstrated 9 factors within the questionnaire. These were function, self-efficacy, effort, optimism, tenacity, self worth, isolation, ability and achievement. The questionnaire was named the Malvern pulmonary rehabilitation motivation questionnaire (MPMQ) for identification. The MPMQ was shown to be reliable with internal consistency, reproducibility on test-retest and sensitivity to change. Correlations were found between the MPMQ and health related quality of life, anxiety and depression, breathlessness, exercise capacity and hospital admissions during the previous 12 months. Motivation score was significantly lower in patients who dropped out of the programme and was significantly higher at the end than the start of a programme.
Conclusion
The MPMQ has been shown to be a reliable tool with sound evidence of validity that can be used to objectively assess patients’ motivation within the context of a pulmonary rehabilitation programme. These findings need to be supported with further evidence for the validity and reliability of the questionnaire. Further investigation of the association of MPMQ score and adherence in pulmonary rehabilitation is needed along with further exploration of the determinants of motivation. This would enable specialist staff to identify patients who are likely to have adherence problems and channel efforts into effective cognitive-behavioural interventions in the ongoing effort to establish the optimum pulmonary rehabilitation programme.