Why we keep going: a qualitative study of the motivation and engagement among patients with COPD during a long-term danish tele-rehabilitation program

<bold>Introduction:</bold> Pulmonary tele-rehabilitation (PTR) is an effective treatment for patients with COPD. However, determinants of sustained motivation and adherence have been sparsely investigated. <bold>Aim:</bold> This study examined how motivation and engagement evolved throughout six months of a maintenance PTR program in patients with moderate to very severe COPD. <bold>Methods:</bold> In a qualitative study with a longitudinal recurrent design, individual semi-structured interviews were conducted after 10 and 35-weeks with 21 patients participating in a randomized controlled trial on pulmonary 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. <bold>Results:</bold> 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 and continuous therapist and peer support were key factors in maintaining adherence. <bold>Conclusion:</bold> Over the course of six months, perceptions of COPD consequences evolved toward greater acceptance, with motivation shifting from fear to a more conscious engagement. The results emphasize the importance of external support and tailored environments for long-term adherence to maintenance PTR programs.