Why We Keep Going: A Qualitative Longitudinal Study of the Motivation and Engagement Among Patients with COPD During a Long-Term Danish Tele-Rehabilitation Program

Introduction: Pulmonary tele-rehabilitation (PTR) is an effective treatment for patients with chronic obstructive pulmonary disease (COPD). However, determinants of sustained motivation and adherence have been sparsely investigated. Aim: This study examined how motivation and engagement evolved throughout 25 weeks of a maintenance PTR program in patients with moderate to very severe COPD. Methods: In a qualitative study with a longitudinal recurrent cross-sectional design, 11 individual semi-structured interviews were conducted after 10 week of Homebased Pulmonary Rehabilitation (HPR) or PTR intervention and 10 interviews were conducted after 25 weeks into the maintenance PTR program with 16 patients participating in a randomized controlled trial on pulmonary tele-rehabilitation at Hvidovre Hospital, Denmark. The interview guide and initial coding framework were directed by the Theoretical Domains Framework in a deductive content analysis. An unconstrained matrix, based on inductive principles, was used to capture categories across multiple domains. Results: Three main categories emerged: (1) Acceptance and Hope, (2) Physical Factors, and (3) External Support. Over time, participants developed greater acceptance of COPD, transitioning from fear-driven motivation to sustained engagement through improved coping strategies. Easy PTR access, continuous therapist, and peer support were key factors in maintaining adherence. Conclusion: Over the course of 25 weeks, motivation evolved from fear-driven to autonomous, reflective engagement. The results emphasize the importance of external support and tailored environments like remote delivery methods for long-term adherence to maintenance PTR programs.