New Zealand Rehabilitation Association, Inc.

Halding, A., Wahl, A., & Heggdal, K. (2010). 'Belonging'. Patients' experiences of social relationships during pulmonary rehabilitation. Disability & Rehabilitation, 32(15), 1272-1280.

Pulmonary rehabilitation is one of the few interventions that has been consistently shown to enhance physical function and quality of life in people with chronic obstructive pulmonary disease (COPD) (Lacasse, Goldstein et al. 2006), and yet, in New Zealand and overseas, the vast majority of people who would benefit from pulmonary rehabilitation do not have access to it (Broad and Jackson 2003; Yohannes and Connolly 2004; Brooks, Sottana et al. 2007; Australian Lung Foundation 2009). Alternatives to the traditional approach to pulmonary rehabilitation (involving group based exercise and education classes) have increasingly been suggested and explored as a way of broadening the availability of pulmonary rehabilitation to a wider group of people. This begs the question: what are the essential elements of pulmonary rehabilitation that make it effective? In other words, what can you do away with or replace in a modified version of pulmonary rehabilitation without undermining the benefits of these types of programmes?

One key characteristic of traditional approaches to pulmonary rehabilitation is the group-based nature of it. So, what might be lost when pulmonary rehabilitation is offered on an individual basis (e.g. to people in their own homes)? In fact, little research has been conducted exploring the contribution of interpersonal interactions during group-based pulmonary rehabilitation classes to outcomes achieved from these programmes. One exception to this is the paper recently published by Halding et al. (2010).

Halding et al. (2010) conducted a phenomenological study to investigate the everyday experience of living with COPD in a group of people (n=18) attending a 12-week pulmonary rehabilitation programme. The results from their study suggested that the social relationships that form during group-based pulmonary rehabilitation may be of ‘great significance for patients in terms of coping and wellbeing' (p. 1275). The central theme identified in this study was one of ‘belonging' whereby, in comparison to their everyday life, pulmonary rehabilitation provided an environment in which the participants could feel understood, where they could share their knowledge with others, and where they could find support and a source for increased self-confidence and motivation for self-care. Central to these findings was the idea that simply being part of a group who shared common experiences and who trusted in one another resulted in improvements in general wellbeing. As a result of their findings, Halding et al. (2010) concluded that ‘successful integration and mutual support within the rehabilitation groups [should] be explicitly stated as a goal of any rehabilitation programme' (p. 1278).

In terms of the generalisability of these findings, there is one consideration that readers should be aware of: each session in the pulmonary rehabilitation programme in Halding et al.'s (2010) study involved five hours of exercise, education, socialisation and social interaction - in other words, almost a full day of activity, once a week for 12 weeks. The strength of group membership achieved in Halding et al.'s (2010) study might not be replicated in pulmonary rehabilitation programmes of shorter duration.

One of the things that surprised me about this study however was the lack of findings that directly linked group-based social interaction to the participants' motivation to strive during the exercise sessions. Increasingly there is evidence that participation in pulmonary rehabilitation can enhance self-efficacy in people with COPD (Garrod, Marshall et al. 2008). Self-efficacy is a psychological construct, first proposed by Bandura in the 1970's, which relates to the belief one has in one's ability to organise and execute a course of action required to achieve desired goals. People with higher self-efficacy are more likely to strive in the face of adversity to pursue their objectives. So, for instance, people with COPD who have a high belief in their ability to undertaking physical activity despite difficulties with shortness of breath are more likely to continue with exercise in the long term.

Bandura proposed that self-efficacy could be influenced by four mechanisms: 1) experience (opportunity to experience success, even if in small areas to begin with), 2) modelling (learning from watching others; "if they can do it, I can as well"), 3) social persuasion (being convinced by others that success is within your capabilities), and 4) physiological factors (how the physical experiences of stress are interpreted by the individual). In the case of Halding et al.'s (2010) study, I would have expected some data relating to modelling and social persuasion to have appeared in the narratives of the people interviewed. However, of the extracts provided by Halding et al.'s (2010), none specifically referred to the experience of watching others exercise or having others comment on one's own progress in exercise. Instead the focus in Halding et al.'s (2010) findings was primarily on this notion of social benefits arising from group membership.

The question which remains for me is how important these social effects are for achieving improved outcomes in terms of physical function and quality of life after pulmonary rehabilitation, and whether or not alternative approaches to developing a sense of group membership (or positive self-identity even) could be achieved without meeting face-to-face for a day a week over a 12 week period.

References

• Australian Lung Foundation. (2009). "Pulmonary Rehabilitation." Retrieved 29 May 2009, 2009, from http://www.lungfoundation.com.au/content/view/109/14/.
• Broad, J. and R. Jackson (2003). Chronic Obstructive Pulmonary Disease and Lung Cancer in New Zealand: Report to The Thoracic Society of Australia and New Zealand.
• Brooks, D., R. Sottana, et al. (2007). "Characterization of pulmonary rehabilitation programs in Canada in 2005." Canadian Respiratory Journal 14: 87-92.
• Garrod, R., J. Marshall, et al. (2008). "Self efficacy measurement and goal attainment after pulmonary rehabilitation." International Journal of COPD 3(4): 791-796.
• Lacasse, Y., R. Goldstein, et al. (2006). "Pulmonary rehabilitation for chronic obstructive pulmonary disease." Cochrane Database of Systematic Reviews: Issue 4. Art. No.: CD003793. DOI: 003710.001002/14651858.CD14003793.pub14651852.
• Yohannes, A. and M. Connolly (2004). "Pulmonary rehabilitation programmes in the UK: a national representative survey." Clinical Rehabilitation 18: 444-449.