Perception of users and their therapists on the factors that interfere with therapeutic adherence at homeAbstract
Non-adherence to rehabilitation can reach 70%. This qualitative, phenomenological study explored the perceptions of 7 users and 6 therapists at a rehabilitation centre, identifying factors that influence therapeutic compliance at home. The results were organised into four dimensions: communication, personal factors, contextual factors, and resources. Among the positive aspects, the availability of time, favourable therapeutic relationships, and personal factors stand out. In contrast, lack of time, negative attitudes, and comorbidities act as barriers. It is concluded that adherence depends on the dynamic interaction between these dimensions. It is recommended to strengthen the communication skills of professionals, incorporate technologies for monitoring, and consider the personal and material aspects of each patient, in order to optimize treatment adherence and improve health outcomes.
Keywords
Treatment adherence; Patient's perspective; Rehabilitation
Resumen
La falta de adherencia en rehabilitación puede alcanzar el 70%. Este estudio fenomenológico cualitativo exploró la percepción de 7 usuarios y 6 terapeutas de un centro de rehabilitación, identificando factores que influyen en el cumplimiento terapéutico en el hogar. Los resultados se organizaron en cuatro dimensiones: comunicación, factores personales, contextuales y recursos. Entre los aspectos positivos se destacan la disponibilidad de tiempo, las relaciones terapéuticas favorables y los factores personales. En contraste, la falta de tiempo, la actitud negativa y las comorbilidades actúan como barreras. Se concluye que la adherencia depende de la interacción dinámica entre estas dimensiones. Se recomienda fortalecer las competencias comunicativas de los profesionales, incorporar tecnologías para el seguimiento y considerar los aspectos personales y materiales de cada paciente con el fin de optimizar la adherencia al tratamiento y mejorar los resultados en salud.
Palabras claves
Adherencia al tratamiento; Perspectiva del paciente; Rehabilitación
Resumo
A falta de adesão à reabilitação pode chegar aos 70%. Este estudo fenomenológico qualitativo explorou a percepção de 7 utilizadores e 6 terapeutas de um Centro de Reabilitação, identificando fatores que influenciam a adesão terapêutica em casa. Os resultados foram organizados em quatro dimensões: comunicação, fatores pessoais, contextuais e recursos. Entre os aspetos positivos, destacam-se a disponibilidade de tempo, as relações terapêuticas favoráveis e os fatores pessoais. Em contrapartida, a falta de tempo, a atitude negativa e as comorbilidades atuam como barreiras. Conclui-se que a adesão depende da interação dinâmica entre estas dimensões. Recomenda-se fortalecer as competências comunicativas dos profissionais, incorporar tecnologias para acompanhamento, e considerar os aspetos pessoais e materiais de cada paciente, a fim de otimizar a adesão ao tratamento e melhorar os resultados em saúde.
Palavras-chave
Adesão ao tratamento; Perspectiva do paciente; Reabilitação
Introduction
Adherence to treatment is defined as the means necessary to achieve health improvements by reducing the signs and symptoms of a disease. These means may include taking medication, exercising daily, or modifying behaviours that are detrimental to health1,2. Adherence is a critical component of any treatment plan. To effectively achieve the desired therapeutic outcomes, users must follow clinical recommendations independently, often without direct professional supervision. Poor compliance can lead to ineffective interventions, resulting in negative consequences for users, therapists, and the healthcare system as a whole3.
In rehabilitation, which often requires complex changes in lifestyle or habits, research has reported that loss of adherence can reach up to 70%4,5.
Several factors negatively impact treatment adherence, primarily those related to cognitive aspects, the interpersonal relationship between the user and the professional, user attitudes, cultural factors, and the patient’s involvement in shared decision-making6-9. Cognitive factors include those related to the user’s understanding of the instructions. Several studies refer to the negative impact on adherence of a lack of health literacy, which is defined as the ability to understand health-related information and concepts received from healthcare professionals1,10,11.
A greater number of instructions provided by the therapist and a higher degree of disability or dependence on a caregiver for treatment also have a negative influence.
The quality of the interpersonal relationship between the healthcare professional and the patient significantly impacts adherence and treatment outcomes, and is linked to the trust established through communication10,12,13.
Participation in therapeutic decision-making has also been described as a factor that promotes increased adherence. Those who have a better relationship with their therapist tend to ask more questions during care and discuss appropriate treatment strategies, a process known as therapeutic concordance or alliance3,14. Similarly, when users and health professionals reach a mutual agreement, they both report higher levels of satisfaction with the care provided15.
According to the background information presented, treatment adherence is a dynamic process involving both therapists and users. To better understand this process, this study aimed to: 1) Identify the factors that influence adherence to home rehabilitation, based on the perceptions of users and their therapists, and 2) Analyze the factors that influence adherence to home rehabilitation, based on the perceptions of users and their therapists.
Methodology
The research was conducted under an interpretive, qualitative paradigm with an empirical, phenomenological design. This design aimed to gather the assessments of users and therapists based on their experiences with the therapeutic process and adherence. Content analysis was used for this purpose16. This methodology was chosen due to the importance of subjectivity in evaluating participation. The use of open-ended questions in semi-structured guidelines encouraged spontaneous discourse, stimulating reflection, meta-reflection, and the articulation of theoretical and practical connections based on participants’ experiences.
This study was approved by the Scientific Ethics Committee of the Araucanía Sur Health Service Office, accredited by Exempt Resolution No. J1-29658, approving the study under File No. 218.
The sample was intentional and consisted of seven users and six health professionals from the rehabilitation team (speech therapy, kinesiology, and occupational therapy) at the Rehabilitation Health Center in the City Hall of Padre Las Casas in the Araucanía Region of Chile. The sample represented all therapists in the neurorehabilitation area of the Health Center.
The Health Center was contacted and informed about the objective and characteristics of the study. The Center then provided the research team with a list of all potential participants. These participants were selected based on two criteria: 1) they had to have stayed at the Center for at least six months, and 2) they had to have received care from two to three therapists.
The health center contacted users by telephone to arrange the interview. A total of eight users were contacted, and seven of them attended. Of those interviewed, two were caregivers of users: one due to the user’s level of dependency and cognitive impairment, and the other because the user was a minor.
Therapists who treated one or more users in the sample were also interviewed.
Two types of semi-structured interviews were designed: one for health professionals and another for users. Three expert judges validated the interviews, which consisted of 15 open-ended questions addressing personal, psychological, health center, and social factors.
Between January and May 2023, seven interviews were conducted with users and 12 with healthcare professionals. For professionals, one interview was conducted for each participating user. However, some therapists treated more than one user and were therefore interviewed more than once. Thus, the seven professionals involved generated a total of 12 interviews. The objective was to explore users’ and their therapists’ perceptions of adherence to home rehabilitation. The interviews, which were conducted in person and online, were recorded after the interviewees signed an informed consent form. The interviews were transcribed accurately. Each interview was assigned a code to ensure anonymity.
Content analysis was used as a qualitative technique to study the interviews in depth. This methodology allowed us to investigate not only the frequency of responses, but also the meanings and significance associated with categories such as adherence, motivation, and commitment, as well as enabling the emergence of new subcategories during the process16. To this end, a thematic matrix was designed to organise the information according to the study objectives, integrating a comprehensive reading of the interviews, the selection of units of meaning, and the recording of contextualised inter-categorical relationships. At the same time, this process led to the creation of new categories, the identification of relationships and comparisons, and the generation of new interpretations as the findings were verified. Following Vieytes’ suggestion16, we sought to transcend quantification, prioritizing interpretations with theoretical and practical value. In addition, we considered the particularities of the collection process, including the types of interviewees, the formulation of questions, the conditions of application and transcription, and the factors that influenced the depth and diversity of the responses.
In this context, content analysis became a tool for articulating the perspectives of users, caregivers, and therapists. It highlighted the tensions, differences, and lessons learned surrounding adherence to home rehabilitation processes.
The results obtained are detailed below.
Results
Table 1 presents the details of the user characterisation.
Results by thematic areas
After content analysis, the results were classified into four dimensions, which are divided into 12 sub-dimensions, summarized below (Table 2):
Communication and follow-up
Recording therapeutic progress
None of the therapists clearly indicated that they should keep a record of the treatment progress at home. Records were informal or consisted of asking the client about the results obtained at the following session.
No, we haven’t recorded it, not really, they haven’t said anything, but anyway, when we get to the next session, we ask them if they did the exercise, what they found difficult, what they didn’t do. (U-C1 / P2)
... A record as such, written down, no... (PS-K2 / U-P2)
In the case of the users, they confirm the information provided by the therapists, emphasizing that they did not keep records of the progress of the treatment.
...perhaps we are at fault, because I don’t keep any kind of personal record at home, there is no written, physical, photographic, or video confirmation that I am doing the exercises. (U-P4)
Despite not using records systematically, professionals value them as a tool that allows them to set goals for progress in rehabilitation, and see them as an opportunity to improve treatment adherence with the implementation of a progress recording system:
Records no [...] If all this were recorded, the patient would have the opportunity to see how they have progressed... (PS-TO3 / U-P7)
Home task monitoring system
During the home work process, a question was asked about a communication system through some type of synchronous or asynchronous messaging. In general, professionals did not communicate with their users outside the center. This is perceived by professionals as an opportunity to encourage adherence to home instructions.
We have talked with some colleagues [...] about having some kind of platform where they can receive information from us in a very organised way. (PS-K1 / U-P1)
Generally, there were no communication channels for users, except for one user who communicated with the professional via instant messaging outside of session hours at the center.
On WhatsApp, I also have her cell phone number, she has said that she will help me with anything, I have had many complicated issues. (U-P6)
Shared decision-making between therapist and user
All interviewees, both therapists and users, say they have the opportunity to make decisions during the treatment process, which has a positive influence on treatment adherence.
[...] she was given, for example, an exercise and always asked if there was lower back pain or not, she said yes, and it was modified; or [she said] this is a little more difficult for me, well, let’s see the alternative. (PS-TO1 / U-P2)
Although shared decision-making is detected, there do not appear to be symmetrical relationships in the process, which is usually led by the therapist.
Understanding instructions for home treatment
Both professionals and users valued the provision of written instructions or recordings of sessions as a mechanism that promotes adherence to home tasks.
[Therapists’ instructions]: “...are usually provided on cards [...] which include images of what needs to be done. (U-P4)
On the other hand, professionals said that greater standardization of these procedures was needed to achieve better results and involve the user’s family.
... [There is a need] to take the time to perhaps provide good counselling and give the instructions as appropriate, perhaps not only to her, but also to someone from the family. (PS-OT3-U-P5)
User-healthcare professional communication
Two users valued the trust they had in healthcare professionals, which we related to their attentive listening to problems.
They are there [to] listen to you [...] always with respect, from patient to professional. (U-P1)
Professionals also viewed this bond positively and believed it influenced adherence positively.
... a good therapeutic-patient bond was achieved [...] she comes in eager to work, you could tell from the way she greeted us, for example [...] I think that good bond was created, which is of course reflected in her willingness to do the exercises. (PS-K1/ U-P2)
However, it is also perceived that this bond still contains a vertical-care approach, in which the therapist was above the user, creating an unbalanced bond:
Most users still have a very care-oriented model in relation to their own health process, so they expect a lot from the team, from a welcoming, paternalistic point of view. (PS-K1 / U-P1)
Personal factors
Age, educational level, and cognitive status
The educational level of users/patients was a factor related to understanding instructions, which, from the perspective of health professionals, promotes adherence to treatment at home:
... he [has] a cognitively demanding education... [so] he has the habit of replicating what is done here at home. (PS-F1 / U-P6)
Age was also an element to consider, mainly in terms of treatment design, and communication and follow-up mechanisms (for example, in the case of older adults who were not familiar with digital technologies).
The healthcare professionals interviewed highlighted cognitive status as an important factor, as it is linked to the need for autonomy and self-sufficiency, which promotes adherence.
The development of basic cognitive skills sometimes prevents them from properly interpreting the information we give them, or from organizing their daily lives to plan their routine... (PS-K1/U-P1)
Users (or caregivers) did not comment on this issue, which shows that they do not perceive these factors in themselves.
Influence of other coexisting health problems on adherence
The question was asked whether other illnesses affecting users influence the implementation of instructions at home. Users cited mental health issues as a relevant factor influencing adherence.
I am undergoing mental health treatment [...] Maintaining good mental health helps rehabilitation, because if I am not well psychologically, I would become depressed and would not carry out the activities. (U-P4)
This opinion was shared by professionals, who reported that users with mood disorders have lower adherence:
[The user goes through] periods of depressive mood disorders, and that affects their adherence. (PS-K1/U-P4)
Attitude, self-efficacy and autonomy
Advances in the levels of self-efficacy and autonomy perceived by users and professionals are one of the main motivating factors in treatment, both in sessions at the Community Rehabilitation Center and in adherence to home exercises.
...staying independent from anyone else, so the exercises they give me here help me stay active and carry out my daily activities, which are quite a lot at home... (U-P4)
On the other hand, health professionals linked previous experience to motivation and users’ levels of adherence to treatment.
...I had some knowledge of a plan related to physical activity [...] I played some sports when I was young... (PS-K1/U-P1)
...He has a lot of previous experience in speech therapy, so it’s easy to give instructions in this case. (PS-F1 / P1)
Contextual factors
Time and space to carry out instructions at home
Participants were asked about environmental factors, such as having enough time and space at home to exercise. Household chores and caregiving are generally perceived as responsibilities primarily assumed by women. Consequently, women often struggle to prioritize personal time and space within the domestic environment.
It’s hard for me to take time for myself, I’m always doing things, [doing] this and that... and never any space for myself, so sometimes I get fed up and I just do it. (U-P4)
Regarding professionals’ perceptions of the time and space needed to perform exercises, it was observed that they were aware of the influence of these factors on the intervention. They recognized the difficulty of finding physical space in homes and the lack of time due to caregiving or work obligations.
[As a factor of non-adherence]… the roles she fulfills at home, as a caregiver… (PS-TO3 / P7)
… users who have smaller homes or whose living conditions are not the most adequate generally do not follow the instructions. (PS-K1 / U-P4)
Family or community relationships [sub-subtítulo]
Family and/or community relationships influence moods and, therefore, the motivation of users/patients.
They help me, they [tell] me: today you have to do your homework, today you haven’t done this, they’re always telling me. (U-P5)
The family or community support network was valued by health professionals as an important factor for adherence to treatment at home.
However, this network can also hinder adherence processes, either because the user/patient is responsible for the care of family members, or because of the emotional tensions that these relationships can cause in users/patients.
... very little family support, really, we’ve always talked about it (...) because he takes care of most of the daily household chores, so, yes, his networks have a big influence. (PS-TO2 / U-P4)
Material Factors
Attendance at the health center
Users valued the assistance and work provided in therapy sessions at the Community Rehabilitation Center, as well as the care provided by health professionals. This is a positive factor for adherence.
They treat you well, the care is very good, and all the attention you receive... (U-C2/P3)
Attendance and participation in the activities organized by the Community Rehabilitation Center influences the motivation of users-patients as a group.
Therapists recognized this motivation, derived from attending the center, which they recognized as a relevant factor in promoting adherence to treatment:
... He comes once a week, but he is committed to his rehabilitation and, in fact, has a very strong bond with the center [...] I have heard him say more than once that he feels at home. (PS-F1/U-P1)
There was a coincidence between the perceptions of users and therapists regarding attendance at the care center.
Availability of financial resources
According to the users’ responses, the economic factor was not considered important for adherence.
Health professionals responded to the question, arguing that the Community Rehabilitation Center provides some minimum conditions for users to attend therapy, in addition to planning their treatment at home, considering low-cost elements, or providing materials to perform tasks at home. In the case of transportation, it is a factor that influences attendance at therapy at the Community Rehabilitation Center, and, therefore, the continuity of treatment at home.
... since materials are provided and [the patient] has transportation, then [...] this does not affect their attendance; if they did not have transportation, the situation would be different. (PS-F1 / P3)
Even when these difficulties are overcome, economic factors influence how much time users devote to at-home treatment. Those who must work independently devote less time than those whose basic needs are met.
... he is self-employed [...] there are days when he does very badly or ... [when] his work only serves to pay his bills, so that also discourages him from his rehabilitation. (PS-TO2 / P4)
Discussion
This study aimed to identify and analyze the factors influencing adherence to home rehabilitation based on user and therapist perceptions. Four main dimensions were identified based on the results and are discussed below.
Communication and follow-up
The results showed that those users and therapists who had better relationships and communication generated greater adherence to home exercises. Guzmán et al.17 highlight the importance of professional and empathetic treatment. Trust, active listening, and empathy, valued by users2,8, strengthen the therapist–patient relationship and increase satisfaction, promoting adherence. Training health professionals in communication strategies has been shown to increase user adherence3,8,14,18, promote decision-making6-8, and improve rapport2.
Therapists recognise the need to spend more time explaining homework assignments clearly and in detail. High demand for care often limits this time, affecting users’ understanding and, therefore, adherence to treatment19.
Understanding instructions is a key factor associated with adherence. Emmerson et al.20 suggest the use of audiovisual records to improve motivation and personalisation of instructions. Effective communication, both verbal and nonverbal, increases user satisfaction21. Therapists should use clear and simple language, avoiding technical terms, and ensure that the user understands. Strategies such as repetition and eye contact are essential.
The results revealed that shared decision-making (SDM) varies among professionals: some allow users to give their opinion on exercises, while others involve them in creating the treatment plan. Studies show that SDM increases satisfaction, adherence, and well-being, particularly among users with chronic conditions requiring an active role in treatment14,18. The model used in the Community Rehabilitation Centre in this study allows treatments to be adapted to users’ needs and reinforces their commitment to home exercises1,18.
Monitoring and recording progress in home treatment are also crucial to promoting adherence to therapeutic exercises. Previous studies support this assertion, indicating that professional supervision improves exercise performance and increases the likelihood of favourable outcomes4.
Hughes et al.22 demonstrated that direct, real-time supervision using technology outperforms self-reporting in terms of the quality of exercise performance at home. The use of technology to monitor the frequency, duration and quality of exercise has shown good results20,23.
Personal factors
Mental health is key to adherence to home tasks. Previous studies point to the negative impact of depression and anxiety on adherence18. According to the results, it is essential that therapists and users be aware of this impact, promoting the detection of risk factors and appropriate referral. In addition, advances in treatment can improve mood by increasing functionality in daily life, as reported by some participants in this study.
Self-efficacy, defined as the ability to achieve a goal, is a key factor in treatment adherence8. This variable should be assessed in each user when predicting adherence24. A personalized treatment plan that considers self-efficacy levels can significantly improve adherence. Unfortunately, the center studied lacked a formal mechanism for measuring adherence, an omission that should be rectified.
Therapists and users agree that self-efficacy and autonomy, as perceived by users, are key to motivation and promote adherence to treatment, both at the centre and at home. These elements were valued positively by both groups, in line with Chen et al.25, who found that greater perceived self-efficacy improves adherence to home exercises.
Regarding personal factors, such as age, socioeconomic status, and cognitive status, although health professionals recognized characteristics of their users that affected treatment adherence, these were not recognized by the users themselves. Although these factors have been described as influential, users’ misconceptions and lack of knowledge about their own condition or disease can be a barrier to adherence8,14. For this reason, it is important to establish a dialogue with users about these factors and their influence on treatment adherence.
Contextual factors
Factors such as time, daily habits and family relationships significantly influence adherence to treatment at home. Lack of time, both for the user and the caregiver, is a common barrier, consistent with previous findings2,10,11,17,26. Dependence on a caregiver with multiple responsibilities reduces adherence, even when the user is motivated.
To improve adherence, it is suggested that instructions be integrated into the user’s daily routine27-29. Family and community relationships also influence motivation and adherence. Although a strong support network is beneficial, in some cases, it can hinder treatment6,11,30.
The results underscore the importance of considering social relationships in treatment planning, as suggested by Jack et al.31. Involving the family or community in the process can improve adherence1,6,10,12,13.
Material factors
Material factors emerged as a crucial aspect in the results. Professionals expressed concern about adapting indications to the economic context of users. However, financial difficulties significantly hinder adherence. As suggested by Moura et al.5, to achieve adequate adherence, it is necessary to guarantee minimum economic conditions that allow time and resources to be devoted to treatment. Therefore, strategies are needed to identify vulnerable patients and adapt practices to improve affordability and, consequently, long-term effectiveness5.
Limitations
This study has certain limitations that should be considered. First, the qualitative, phenomenological design could limit the possibility of generalising the findings to other contexts. Likewise, the small sample size may have limited the diversity of perspectives and the interpretive richness of the results. Despite these limitations, the research makes a significant contribution by identifying the factors that influence therapeutic adherence from the joint perspective of users and their therapists.
Recommendations for practice
Based on the findings and evidence reviewed, six recommendations are proposed. First, promote ongoing training for professionals in communication skills, active listening, and empathy, competencies that improve understanding of instructions, build trust, and encourage shared decision-making. In this regard, the use of audiovisual resources can enhance the clarity and personalisation of instructions. Second, the active participation of users in planning their treatments and in decision-making increases their sense of autonomy and commitment, promoting adherence. Third, implement follow-up mechanisms, both in-person and technology-mediated, that allow progress to be recorded and ensure tasks are executed correctly at home. These mechanisms reinforce motivation and continuity of treatment. Fourth, evaluate personal variables, such as self-efficacy, mental health, and self-worth, as early detection enables timely referrals and appropriate adjustments to the therapeutic plan. Fifth, integrate treatment into daily routines, and consider the role of family and support networks as key elements in promoting continuity of therapeutic practices. Sixth, consider material factors, identifying users in situations of economic vulnerability, and adapting treatment strategies to their possibilities, in order to reduce barriers and ensure both accessibility and sustainability of rehabilitation.
Conclusion
This study showed that perceptions of adherence to home-based rehabilitation depend on the dynamic interaction of communicational, personal, contextual, and material factors. The quality of the therapist–user relationship, together with clear, empathetic communication geared toward shared decision-making, is central to promoting understanding and commitment to therapeutic tasks. Likewise, individual variables such as self-efficacy, mental health, and perception of self-efficacy have a decisive influence on motivation and continuity of exercises. The findings also highlight the impact of the family, social, and economic environment, underscoring the need for strategies adapted to the daily realities and vulnerable conditions of users.
Acknowledgments
To the Padre Las Casas Community Rehabilitation Center, its professionals, and especially its director during the study period, Danner Burgos, for their support in the planning and sampling process. We would also like to thank the individuals (users and caregivers) who participated by providing their testimonies in response to the questions, and who kindly collaborated with the project. We would also like to thank the Catholic University of Temuco for providing financial support for the research.
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Rodríguez D, Fuentes-Ugarte, Cuevas-Zepeda L, Hunter-Echeverría K, Burdiles NF. Perception of users and their therapists on the factors that interfere with therapeutic adherence at home. Interface (Botucatu). 2026; 30: e260091 http://doi.org/10.1590/interface.260091
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Funding
This study was funded by the Catholic University of Temuco through the Internal Interdisciplinary Research Project of the Faculty of Health Sciences, funded in 2021.
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Translator
Michael Geoffrey Handford
Data Availability
The dataset supporting the results of this study was made available in SciELO Data and can be accessed in: https://doi.org/10.48331/SCIELODATA.V2HJJE
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Edited by
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Editor
Roseli Esquerdo Lopes https://orcid.org/0000-0001-9572-4586
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Associated editor
Késia Melo https://orcid.org/0000-0003-1397-2688
