The psychosocial determinants of adherence to home-based rehabilitation strategies in parents of children with cerebral palsy: A systematic review

The psychosocial determinants of adherence to home-based rehabilitation strategies in parents of children with cerebral palsy: A systematic review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review The psychosocial determinants of adherence to home-based rehabilitation strategies in parents of children with cerebral palsy: A systematic review Japhet Niyonsenga, Athanasie Bugenimana, Inès Musabyemariya, Jean Baptiste Sagahutu, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3079847/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Jun, 2024 Read the published version in PLOS ONE → Version 1 posted You are reading this latest preprint version Abstract Background Involving parents of children with cerebral palsy (C-CP) in home exercise programmes (HEP) is globally practised and closely linked to improved treatment outcomes for physical performance and function. Nevertheless, non-adherence to HEP is increasing at an alarming rate, and little is known about the factors of adherence to HEP (AHEP) especially in parents of C-CP. Objective This systematic review was aimed to identify the factors enhancing AHEP among parents of C-CP to reinforce the efficacy of rehabilitation practices proposed by health professionals, researchers, and educators. Method We searched PubMed, Scopus, CINHAL, PsycINFO, and Embase for articles published up to March 2023, that investigated the factors of AHEP among parents of C-CP. We conducted a narrative synthesis using the search results and pertinent material from other sources. Results Overall non-adherence rates to HEP were moderate to high (34%-79.2%). There was strong evidence that factors enhancing AHEP are in three categories: child-related (low age and gross motor function (GMF), caregiver-related (high self-efficacy and knowledge, high social support, low depression, anxiety and stress symptoms, and low perception of barriers), and the physiotherapist-related. For the last category, parents’ perception of a supportive and collaborative relationship with the therapists is one of the conditions mostly favour AHEP. Conclusions Our findings highlight that factors influencing AHEP are multifactorial. Some of them are conditions that are difficult to change such as FGM or the economic and social conditions of the family. Instead, the relationship between therapist and parent is a dimension that can be strengthened. These results suggest the importance of substantial training and psychosocial support for the therapists to make them more aware of and competent in the need to build a supportive relationship with parents. Home-based exercise programs cerebral palsy self-efficacy depression anxiety social support and gross motor function. Figures Figure 1 1. Background CP is the largest diagnostic group treated in paediatric rehabilitation. [ 1 , 2 ] Cerebral palsy (CP) is a spectrum of motor development problems caused by persistent damage to the immature brain [ 3 ] . The most frequent CP manifestations are deficits in sensory, communicative, cognitive, and musculoskeletal functioning that may severely limit the autonomy of children in their daily life. [ 1 , 2 , 4 ] Social participation, independence, and self-efficacy are restricted in children with CP, and about 60% of them have problems with the effective use of the arm and hand during reach, grasp, release, and manipulation of objects resulting in limitations in the performance of daily activities. [ 1 ] CP has common comorbidities such as epilepsy, standing at 35%-66.36% [ 5 , 6 ] , speech impairment (43.5%), visual impairment (25%-58%), [ 6 , 7 ] and cognitive impairment (24%). [ 6 ] According to data from national cerebral palsy registries and population-based research in Europe, Australia, and the United States, the prevalence of CP is around 1.8–2.3% per 1000 children [ 8 – 10 ] . In contrast to the high-income countries, the prevalence of CP in Africa might reach up to 2–10 per 1000 live births [ 11 , 12 ] . While the main factors of CP in high-income countries are premature or low birth weight, [ 13 ] in Africa the major contributors are birth asphyxia, kernicterus, central nervous system infections and congenital and neonatal infections which are more easily preventable. [ 5 , 12 ] Although the consequences of CP are permanent, early intervention programs have been shown to increase children’s independence and quality of life, especially when applied between the ages of birth and five, when neuroplasticity is at its greatest. [ 14 – 16 ] Early intervention allows C-CP to reinforce their remaining potential abilities by tackling their initial movement limitations. Besides professional intervention, the efficacy of rehabilitation depends on consistent, proper home exercise programs (HEP). HEP is a kind of treatment extension in which, in a paediatric context, a medical professional trains parents or caregivers on how to carry out the recommended program at home and between physical therapy visits. [ 17 , 18 ] To achieve an effective outcome, the HEP frequently accounts for 50–80% of total therapy received by children with CP (C-CP). [ 18 ] The positive effects of HEP are not limited to children as, according to Novak, it can increase parental satisfaction [ 19 ] . Moreover, HEP is important for rural families since it saves time and money while also involving parents in treatment decisions and allowing them to select what is best for their child. [ 1 , 20 ] Nevertheless, Adherence to HEP (AHEP) in rehabilitation is a significant problem. The rate of non-adherence is estimated to range from 50–66% [ 21 , 22 ] and it is expected to be significantly higher in poor-resource settings. [ 21 ] Parental non-adherence was reported to be the primary reason for treatment failure in long-term paediatric diseases [ 21 ] and it appears to be related to unnecessary and harmful changes in the treatments proposed by health professionals. Given this, a systematic review to explore the factors determining parental adherence/compliance to HEP is needed. In a recent systematic review on predictors of adult patients’ adherence to home-based physical therapies, authors concluded that intention to engage in home-based physical therapy, self-motivation, self-efficacy, previous adherence to exercise-related behaviours and social support were robust predictors of adherence. [ 23 ] Similarly, another systematic review on barriers to treatment adherence in physiotherapy outpatient clinics, showed that poor treatment adherence, in general, was associated with low levels of physical activity in previous weeks, low self-efficacy, depression, anxiety, helplessness, poor social support, greater perceived number of barriers to exercise and increased pain levels during exercise among muscle-skeleton physiotherapy patients. [ 24 ] However, very little attention has so far been paid to the factors influencing the AHEP among parents of C-CP and no systematic review has been conducted to date. With this research gap in sight, the presented study was designed to provide an overview of the factors that influence parents’ compliance with HEP for their C-CP as one of the robust rehabilitation strategies leading to the best clinical outcomes. Identification of barriers may help clinicians identify parents at risk of non-adherence and suggest methods to reduce the impact of those barriers thereby maximising adherence. 2. Methodology 2.1 Study design This systematic review follows the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA). The PRISMA guidelines provide items informed by empirical research for systematic reviews and meta-analyses. [ 25 ] 2.2. Search strategy and selection criteria The sources of information that were used are Medline through PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINHAL), PsycINFO, and EMBASE. The search strategies for this review were established by applying Boolean operators to connect the descriptors. The descriptors were derived using a keyword and Mesh terms search (in PubMed) in each database's metadata system. The search terms were specially designed for the relevant database and comprised: terms relating to home exercise programs (e.g. 'exercise\therapy', 'physiotherapy', 'home physiotherapy', 'home exercises', 'rehabilitation exercises'); terms concerning adherence (e.g. 'adherence', 'compliance', 'treatment compliance', 'parent engagement', ‘parent involvement’); terms referring to factors (e.g. 'barriers', ‘factors’, 'facilitators', determinants', ‘predictors') and terms referring to cerebral palsy (‘cerebral palsy’, ‘neurodevelopmental disorders’, ‘quadriplegic’, ‘monoplegia’ and ‘diplegia’). Two separate researchers searched (JN, BA). A third reviewer (MN) facilitated decision-making when there were disagreements. Studies yielded by the search strategy were eligible for inclusion if (i) the concerned parents of children with CP younger than 18; (ii) The exercises were assisted by a caregiver and not done by the patient himself; and (iii) the articles were in English. Notably, studies that included both clinic and home-based exercise adherence data were included if home-based data were reported separately. We excluded the following: (i) review articles; (ii) studies addressing children without confirmation of a CP diagnosis; and (iii) studies not available in their entirety. The initial choice was determined using the Boolean association of descriptors, followed by reading the titles, summaries, and eventually the complete article. We imported all references into our Covidence database ( https://www.covidence.org ) for deduplication against other sources and screening according to the same inclusion criteria. The number of articles detected in electronic databases and excluded articles were rigorously reported in Fig. 1 . After identifying pertinent papers, their reference lists were hand-searched for more relevant literature. The papers chosen were tabulated at the end of the selection process for data collection, tabulation, and analysis, as well as later data interpretation and description. 2.3. Data extraction and management Study characteristics and outcome data were extracted by one reviewer using a pre-designed data extraction spreadsheet. The information extracted for analysis was divided into three categories: study data, data about children with CP, and data about the parents. The following study details were extracted: study title, author(s), publication year, country of study, study design, participant characteristics ( e.g ., child’s age range, parents’ mean age) and the measure of adherence to the home exercise program. If some of the articles did not contain all the data required for the review, we included the available data (Table 1 ). Table 1 Summary of the main study characteristics and the key findings Key findings Authors, year and titles Sample details Non-adherence Rate child’s age Concept (and measure) of Adherence to HEP Univariate analysis Multiple regression analysis Study quality (NOS/ CASP) BAŞARAN et al. (2014). Adherence to Home Exercise Program among Caregivers of Children with Cerebral Palsy 147 parents (43.5% females, mean age [MA] = 34.3), Turkey 52.9% 2–18 years A self-designed questionnaire with three close-ended questions assessing adherence. Gross motor function classification system, OR = 1.50, p = 0.01), Emotional exhaustion, OR = 0.92, p < 0.001), Depression and anxiety were significantly not associated with adherence. NOS-7 stars Alwhaibi et al. (2022). Factors Affecting Mothers’ Adherence to Home Exercise Programs Designed for Their Children with Cerebral Palsy 109 parents (99 females, MA = 33.7, Saudi Arabia 66.10% Below 12 years An adapted questionnaire composed of 17 items scored on a 5-point Likert scale. Social support, β = 0.156, p = 0.041. Health professionals’ behaviour, β = 0.268, p = 0.026. Mother’s sense of unsureness, β= -0.306, p = 0.003 NOS-8 stars Lillo-Navarro et al. (2019). Factors Associated with Parents’ Adherence to Different Types of Exercises in Home Programs for Children with Disabilities 219 parents (85% female; MA = 34.3), Spain 54.2% Not specified Adherence was assessed according to the prescribed dosage of the HEP on a 5-point Likert scale (1 = never, to 5 = always). Education level, OR = 0.40, p < 0.05. Child inability to maintain sitting, OR = 2.12, p < 0.05, Low perception of barriers, OR = 2.7, p < 0.001. High knowledge and ability, OR = 5.68, p < 0.001 High self-efficacy = 3.28, p < 0.001 Child inability to maintain sitting, OR = 2.65, p < 0.001, Low perception of barriers, OR = 2.52, p < 0.001. High knowledge and ability, OR = 3.69, p < 0.001, Giving information about evolution, OR = 6.27, p < 0.05; Justifying usefulness of exercises, OR = 9.49, p < 0.001; Using the child as a model, OR = 2.72, p < 0.05; Asking about adherence at home, OR = 2.98, p < 0.001; Parents’ high satisfaction with the care received, OR = 1.71, p < 0.05 NOS-9 stars MEDINA-MIRAPEIX et al (2017). Predictors of parents’ adherence to home exercise programs for children with developmental disabilities, regarding both exercise frequency and duration: a survey design 219 parents (8 males, 99 females; MA = 34.3), Spain 42.8% 0.5-6 years Adherence was assessed according to the prescribed dosage of the HEP on a five-point (1 = never, to 5 = always). Low perception of barriers, OR = 5.68, p < 0.001. High knowledge and ability, OR = 2.18, p < 0.001 High self-efficacy = 6.82, p < 0.001 Social support, OR = 2.04, p < 0.001 Age < 2 years, OR = 1.99, P < 0.05, Child inability to sit, OR = 2.23, p < 0.05, In treatment < 2 years OR = 2.3, p < 0.05, Low perception of barriers, OR = 4.83, p < 0.001; High self-efficacy, OR = 6.67, p < 0.001. High knowledge and ability, OR = 2.21, p < 0.001. Social support, OR = 2.97, p < 0.001. Age < 2 years, OR = 2.09, p < 0.05 Child’s inability to walk, OR = 3.02, p < 0.001, Information about progress, OR = 3.75, p < 0.05, Justifying usefulness of exercises, OR = 2.17, p < 0.05 Advising to insert HEP into daily, (OR = 2.54, p < 0.001) Checking skills, OR = 2.21, p < 0.05. Asking about adherence at home, OR = 2.20, p < 0.001 Parents’ high satisfaction with the care received, OR = 1.71, p < 0.05 NOS-9 stars Rone-Adams et al. (2004). Stress and Compliance with a Home Exercise Program Among Caregivers of Children with Disabilities 66 parents, South Florida 66% Below 18 years A self-designed questionnaire of six close-ended questions was used to assess HEP. The level of stress (F = 4.417, p < 0.039, R 2 = 0.065). Parent and family problems (r = 0.345, p = 0.005). NOS-6 stars Sel et al., (2020). Parents of children with physical disabilities perceive that characteristics of home exercise programs and physiotherapists’ teaching styles influence adherence: a qualitative study 155 parents, Turkey 47.1% 2–18 years 28 items Validated Questionnaire measuring adherence. Depression and anxiety (r=-0.405, p < 0.001), medication use (r=-0.233, p = 0.003), Device use (r = 0,741, p < 0.001) Health professional attitudes (r = 0.221, p < 0.001) Gross motor function classification system, p < 0.01), NOS-7 stars Tahayneh et al., (2020), Factors affecting mother’s adherence towards cerebral palsy home exercise program among children at hebron and bethlehem, Palestine 48 mothers, Palestine 35.4% 1–3 years A self-reported questionnaire was used to assess adherence on a 5- point Likert scale (5 strongly agree to 1 strongly disagree) The socio-economic, work, age, education and marital of mothers were not associated with HEP NOS-6 stars Gmmash et al. (2021). Parental Adherence to Home Activities in Early Intervention for Young Children with Delayed Motor Development. 446 participants (96% females), USA Not available A self-reported questionnaire was used to assess adherence Therapists’ modelling of the activities (r = 0.5, p < 0.001), parent’s self-efficacy in the application of Home activity ([HA], r = 0.6, p < .000), HA enjoyed by a child (r = 0.5 p < .0001), HA appropriate for daily routines (r = 0.7, p < .000), HA appropriate for daily routines (r = 0.7, p < .000), HA appropriate for home environment (r = 0.6, p < .000), HA includes child’s sibling and extended family (r = 0.3, p < .000) were all significantly associated with adherence to HA NOS-7 stars [ 37 ] . Compliance with home rehabilitation therapy by parents of children with disabilities in Jews and Bedouin in Israel 193 participants, Israel 79.2% of Jews 0.6-6 years Compliance was measured by two questions from the validated questionnaire. The strongest factors significantly and positively associated with adherence to HEP were being Bedouin, parents’ education, hopefulness, the belief that exercise will improve functioning, satisfaction with the services and socioeconomic status, whereas the intensity of questioning destiny reduced adherence. NOS-7 stars [ 40 ] . Home activity programs in families with children presenting with global developmental delays: evaluation and parental perceptions 45 participants (90.3% females) Canada 31.1% 6–8 years A self-reported questionnaire. Social support and negative feelings such as motivation, hope, confidence, being more realistic and being at ease and satisfied with the idea of HEP were positively associated with adherence. But adherence was inversely related to the difficulty to integrate exercise into daily life and negative feelings such as burden, guilt, and discouragement. NOS-6 stars [ 38 ] . Investigation of parents' compliance in physical therapy at home with toddlers diagnosed with cerebral palsy 63 parents (51% female) Greece 60% 1–6 years A self-reported questionnaire simple, comprehensible, fun exercises, therapeutic support from the physiotherapist, personal communication and understanding, training of the parents, and involvement of parents in physiotherapy improve adherence to HEP. However, fear of causing pain and negative parents’ view of physiotherapy reduce adherence. NOS-6 stars Demeke et al., (2023). Home-based therapy and its determinants for children with cerebral palsy, exploration of parents’ and physiotherapists’ perspective, a qualitative study, Ethiopia 17 participants (27–39 years), Ethiopia Not available 1–4 years Individual, face-to-face, and semi-structured interviews Low family support, limited recourse, lack of knowledge and poor attitude negatively affected adherence to home-based therapy. CASP-10 stars [ 35 ] . Parents of children with physical disabilities perceive that characteristics of home exercise programs and physiotherapists' teaching styles influence adherence: A qualitative study 28 participants, Spain Not specified 0.5-6 years Focus group discussion Two key themes related to adherence were the characteristics of the HEP (the perceived effects of the exercises, their complexity, and the number of exercises undertaken) and the characteristics of the physiotherapist’s teaching style (when their physiotherapist tried to build parents’ confidence in the exercises, helped the parents to incorporate the HEP into their daily routine, provided incentives and increased motivation). CASP-10 stars 2 .5. Quality assessment The Newcastle-Ottawa Scale adapted for cross-sectional studies was used to evaluate the methodological quality of the quantitative studies because all review studies were explicitly of this type. [ 26 ] The scale rates evidence quality based on selection, comparability, and outcome, with stars assigned based on the NOS coding handbook. A maximum of five stars might be given for selection, two for comparability, and three for the outcome. The number of stars granted indicates the quality of the study. The Critical Appraisal Skills Programme Tool for Qualitative Research (CASP) was used to assess the quality of the qualitative studies included in the review. The tool consists of 10 criteria that evaluate a study's methodological rigour and validity. [ 27 ] A rating approach was used to determine relative study quality. [28] Studies were classified as 'high quality' if they satisfied at least eight of the ten criteria, 'moderate quality' if they met 5–7 of the criteria, and 'poor quality' if they met four or fewer. 2.6 Data synthesis The first plan was to do a meta-analysis. Unfortunately, there was little data provided in the studies found by this review, and the data that was gathered was inconsistent in terms of measures employed (7 out of 9 were self-designed) and analysis undertaken. As such, it was decided to conduct a narrative synthesis rather than a meta-analysis to synthesize the data in the most meaningful way possible, guided by the concepts described by Popay and colleagues. [ 29 ] A narrative synthesis approach was used to describe, compare, and combine findings from multiple studies. This method concentrates on textual summaries and results descriptions with the primary goal of "telling the tale “of the findings from the included research. [ 29 ] The elements of this process in this review included: developing a preliminary synthesis to organize the findings from the included studies; exploring relationships within this data to understand and explain patterns or differences; and assessing the robustness of the synthesis by considering the strength, quality, and generalizability of the included data. 3. Results 3.1. Characteristics of included studies. The search resulted in 432 records. After deduplication, a total of 342 titles and abstracts were screened, resulting in 326 irrelevant records. The remaining 16 records were full texts assessed for eligibility, of which three did not meet the eligibility criteria. The search resulted in 13 records. The flow chart of the literature search is illustrated in Fig. 1 . There were 13 corresponding and last authors contacted to provide any related studies. Of these authors, 8 (59%) responded with either a suggestion or no additions at all, resulting in two additional records already included in the 13 records. Eleven quantitative and two qualitative studies addressing the factors influencing parents’ HEPA were included in the final review (Table 1 ). Three studies were conducted in Spain, two in Turkey, two in the USA, and one in each of these countries: Saudi Arabia, Ethiopia, Israel and Palestine. Three studies were published between 2000 and 2005, and the remaining 10 studies were published between 2013 and 2023. Though all studies' samples were mixed, sample participants were predominantly female, with percentages ranging from 51–99% of the total sample. Sample sizes also varied greatly ranging from 17 to 446 participants. The mean age for all studies was closely 34 years old for parents whereas the age range for children was 0.5–18 years. All adherence measures included participant self-report. The adherence results were often dichotomized into 'adherent' and 'non-adherent' individuals for analysis or expressed as a percent of the suggested exercise done. 3.2. Quality assessment of the included articles. For the appraisal of the quantitative studies, two studies were awarded 9 stars, one study was awarded 8 stars, four were awarded 7 stars, one was awarded 8 stars and the rest four studies were awarded seven stars (Table 1 ). The biggest concern discovered during the quality assessment was that all studies employed convenience sampling, meaning that participants may not represent the research population. Except for one study, [ 30 ] the rest did not use power analyses or sample size estimates to support their sample size. Although there are no universal guidelines for determining the optimal sample size for multivariate analyses, a small sample size may lead to less confidence in the results. [ 31 ] Although considering the kind of target population, the convenient sample is reasonable, the authors would adapt appropriate analysis according to the quality of their sample. Therefore, variations in the study sample sizes may explain inconsistencies in significant findings for a specific factor. Furthermore, response rates were low throughout the studies, with no description of the characteristics of non-responders provided. Therefore, determining how representative the participants were challenging. [ 23 ] Parents who were most adherent to HEP may have been more willing to participate in the research because they saw it as relevant and valuable. Conversely, non-adherent parents could prefer not to talk about it and not take part in the research. [ 23 ] Notably, non-validated measures of different concepts were often used and the scale reliability evaluations for the given sample were not always conducted [ 22 , 32 , 33 ] or did not always indicate adequate reliability. Moreover, all studies employed self-report methods to assess HEPA and its associated factors, which rely on individuals properly remembering and reporting their exercises. Therefore, individuals are vulnerable to social desirability and memory biases, which can lead to overestimation of adherence. This agrees with the findings of a previous systematic review of self-report measures of general adherence to home-based rehabilitation programs which showed that all 61 identified measures lacked psychometric validity. [ 34 ] The current review found that factors such as social support and self-efficacy were also assessed by a single item derived from their related validated scales that may not effectively assess target concepts. [ 33 , 35 ] Other research attempted to address these concerns by developing new measures based on existing scales or theories in the scientific literature [ 20 , 33 , 35 ] or by pre-testing and piloting the scales. On the other hand, two qualitative studies included in the review were of high quality in terms of their approach to participant recruitment, data collection and analysis (Table 1 ). All these studies adequately considered the role of the researcher and how they might influence the study results. “ Table 1 : Summary of the main study characteristics and the key findings ” should be here. 3.3. Factors influencing the adherence to home exercise programs among parents of children with cerebral palsy. Our analysis identified several psychosocial and situational factors that have been considered in the literature to date, and were grouped into four conceptually related categories: Child related factors, caregiver-related factors, and therapist guidance and advice. We relied on the descriptive information supplied in the original articles to address our secondary research aim of identifying the specific factors that are perceived to be beneficial or detrimental in adhering to HEP among parents of C-CP. 3.3.1 Child-related factors of HEPA Gross motor function Four quantitative studies showed an inverse relationship between gross motor function and HEPA [ 32 , 33 , 35 , 36 ] . These studies evidenced that parents’ adherence appeared to be higher when the gross motor function was low. Child age, gender, and weight Four quantitative studies conducted showed mixed findings on the association between child age and HEPA. [ 32 , 33 , 35 ] While two studies revealed no associations between child age and HEPA, [ 32 , 35 ] one study showed a positive association, indicating that parents with younger children were more likely to adhere. [ 33 ] Two separate quantitative studies found no associations between the child’s gender, [ 35 ] the child’s weight [ 32 ] and HEPA. 3.3.2. Caregiver-related factors of HEPA Education level, age, and marital status Four quantitative studies have consistently revealed that mothers’ educational status was positively related to adherence. [ 22 , 35 , 37 , 38 ] These studies suggested that parental education helps parents feel less anxious about injuring or causing harm to their children. Further, the association between the caregiver’s age and HEPA was inconsistent. [ 20 , 32 , 33 , 39 ] Only one study out of four indicated significant positive associations [ 32 ] . There was also strong evidence that marital status [ 20 , 32 , 33 ] and the household number of children were not related to HEPA among parents. [ 20 , 33 , 35 ] Depression and Anxiety Two quantitative studies showed significant negative associations between parental depression and anxiety, and HEPA [ 36 , 38 ] and were complemented by one qualitative study. [ 40 ] These studies strongly evidenced that the severity of depression and anxiety symptoms were salient risks of non-HEPA. The only study where this association was not significant [ 32 ] is characterized by a weak methodological design (Table). This weakness can be traced to the sample predominated by fathers (51%) who are not usually involved in HEP [ 39 ] and a non-validated self-report measure of adherence. [ 32 ] Stress and emotional burden/exhaustion Three articles highlighted that mothers’ sense of insecurity and doubts about their ability to complete exercises and burnout level, [ 32 , 40 ] level of stress, and family problems [ 22 ] were detrimental to parents’ HEPA. Positive Cognitions Of 13 studies included in this review, five quantitative studies have investigated cognitive factors such as high self-efficacy, high knowledge and ability, and low perception of the barriers that enhance parents’ HEPA. [ 30 , 33 , 35 , 40 ] According to these studies, all these factors are positively correlated with HEPA. Social support Social support is the perception and experience that one is taken care of, that supportive resources are available from others, and, most commonly, that one is part of a social network that is supportive. Although social support may involve several types of support, it was only assessed through one item and identified as a potential factor enhancing the likelihood of HEPA in four quantitative studies evidenced. [ 20 , 33 , 35 , 40 ] The same result was reported in one of the qualitative studies included in the review [ 41 ] which was carried out through individual, face-to-face, and semi-structured interviews. Family Income and equipment There were mixed findings on the positive association between family income and adherence in five quantitative studies, with some studies indicating significant positive associations [ 22 , 33 , 37 ] and no significance. [ 20 , 39 ] Also, the availability of the home equipment necessary for the exercises did not affect the level of parental HEPA. [ 33 , 35 ] Despite few studies conducted, these results indicate that parents do not any special equipment to adhere to HEPA. 3.3.3 Therapist Guidance and Advice Amount of exercise The number of exercises prescribed by health professionals was investigated by two studies: a quantitative study [ 22 ] and a qualitative study. [ 42 ] These studies highlighted that the more exercises prescribed, the less likely parents were to adhere to the recommendations. Healthcare professionals thus, need to take care of this while designing HEP for parents of C-CP. Exercises that improve outcomes There were consistent findings on the positive associations between parental perception of the benefits and efficacy of exercise and HEPA in five quantitative studies [ 22 , 30 , 33 , 37 , 40 ] and complemented by one qualitative study [ 42 ] which may support the generalisability of the findings. In this case, it is thought that parents are highly motivated and hopeful when their children’s conditions improve thanks to exercises performed. [ 37 , 40 ] Exercise without adverse effects on Children The perceived adverse effects or pain of the exercises on C-CP were found to be negatively related to HEPA in two quantitative studies. [ 22 , 38 ] This finding was complemented by the qualitative study, which recognized pain as detrimental to HEPA. [ 42 ] Therefore, it can be concluded that the presence of pain or adverse effects during exercise plays a crucial role in executing and adhering to HEP. Easy and enjoyable exercises Three quantitative studies continually reported enjoyable and easy exercises [ 22 , 38 , 40 ] as potential factors of HEPA, demonstrating a largely positive relationship in multivariate analyses. This was also confirmed in one qualitative study. [ 42 ] As such, an effective home treatment program should contain easy, understandable, and entertaining exercises that are suited to daily activities. Physiotherapist’s Support The relationship between support from the physiotherapist and HEPA was investigated in seven quantitative studies [ 20 , 30 , 33 , 35 , 36 , 38 , 40 ] and a qualitative one. [ 42 ] There was mounting and consistent evidence that parents were more likely to adhere to home exercises when they were satisfied with the care from their therapist [ 33 , 35 – 37 ] and informed about the progress and clarification of doubts. [ 33 , 35 ] Further, parents who were motivated by the therapist advised to insert exercises into daily routines, assessed their skills, or asked about adherence at home by their therapists were more likely to comply with home exercises. [ 20 , 33 , 35 , 38 , 40 , 42 ] Yet, some authors [ 43 ] have highlighted the risk that this follow-up may lead to stress and feelings of guilt in parents. Similarly, Lillo-Navarro and his colleagues [ 35 ] suggested that healthcare providers must be aware of this circumstance to be perceived as a source of assistance rather than a judgemental bystander. Discussion The specificity of this systematic review lies in the fact that it is focused on paediatric home-based rehabilitation strategy and the indispensable role played by caregivers in this process. The prior reviews emphasized factors of adherence to home-based therapies [ 23 ] and clinical-based therapies [ 24 ] among adult patients, but none have been conducted specifically for paediatric patients. In the previous reviews, the predictors of adherence to home physical therapy by adults sufficiently self-reliant to be able to participate in the research are assessed from the patient's own experience. In those cases, poor treatment adherence, in general, was found to be associated with low levels of physical activity in previous weeks, poor social support, low self-efficacy, greater perceived number of barriers to exercise, helplessness, self-motivation, increased pain levels, [ 23 ] depression, and anxiety during exercise among adult muscle-skeleton physiotherapy patients. [ 24 ] To the best of our knowledge, this is the first systematic review that objectively assesses the factors influencing adherence to home exercise programs among mothers of C-CP. The results of the quality assessment of 13 studies included in this review showed that most of them were of high quality. We found strong evidence of three categories of factors influencing HEPA: child-related factors (gross motor function), caregiver-related factors (education level, depression, and anxiety, stress, emotional exhaustion, high self-efficacy, high knowledge and ability, and low perception of the barriers, and social support), and therapist’s guidance and advice (amount of exercise prescribed, exercises that improve outcomes, exercise without adverse effects, and physiotherapist’s support). Each of these factors is important in the paediatric rehabilitation of C-CP not so much because of their direct impact on the patient but mainly because they contribute to reinforcing or counteracting the mother's level of adhesion. When faced with patients with severely reduced autonomy, be they children, the elderly or the severely disabled, adherence to care can only depend on the adherence of the caregiver him/herself. But this caregiver is not simply a transmitter of deliveries or an executor of orders. He/she too has own struggles, fears, hopes, and convictions. Consistently, one unique and interesting factor that emerged in the current review is the physiotherapist’s guidance and advice. It is fair to believe that when therapists focus on enhancing parents' knowledge and abilities by offering information, [ 44 ] explaining the use of exercises, [ 45 ] and using the child as an example improves adherence. It further emerged that when parents were given information about the benefits of exercise, it greatly boosted their chances of adhering to HEP. This might be owing to a better knowledge of a cause-effect relationship, which improves adherence rates, particularly for activities that parents find more difficult to complete. It was also found that mothers may have higher adherence to some types of exercises than others. These findings are in concordant with those reported previously showing that most parents see flexibility exercises as unpleasant and complicated activities. [ 46 ] As such, while planning treatments with families, therapists should consider their effect on adherence to these sorts of exercises. While the factor represented by gross motor function is a given condition that does not depend on subsequent interventions, the ability to perform HEPA consistently can substantially improve patients' living conditions by recovering parts of the functions impaired by paralysis. With paediatric patients, the performance of HEPA is strictly dependent on the caregiver's adherence to the physiotherapist's recommendations. Having a child with a disability place parents in having to accept an 'unacceptable' situation. Parents are likely to be affected by their child's difficulties and suffering and are therefore more at risk of developing psychosocial problems that may in turn affect the well-being and rehabilitation process of children with cerebral palsy. Thus, the effectiveness of the physiotherapist's prescriptions will depend on the latter's ability to build a relationship of trust with the caregiver. The results that emerged from this review attempted to bridge the literature gap by providing comprehensive and updated literature on the factors affecting HEPA. Our findings emphasised the integration of the concept of “care “to create a more favourable condition to achieve the cure rather than a sole consideration of the concept of “cure” which is often used in healthcare practices without thought to the social, cultural, and psychological implications of its meaning. [ 47 ] As such, the "cure versus care" dichotomy which states that family members believe it is the responsibility of professionals to cure their patient while they are responsible for providing care, captures the natural preference of families in Rwandan culture to be involved in the care of their children with cerebral palsy. Study strengths and limitations This review was rigorous and used a strong methodological approach to discover, appraise, and synthesize significant findings. The search parameters were intentionally broad to locate research examining a wide variety of factors that may impact HEPA among parents of children with cerebral palsy. It also used a robust quality criteria tool to assess the articles included in the synthesis. Nevertheless, our findings should be interpreted considering the methodological limitations of included studies and the review itself. First, a small number of studies exploring several factors, studies' methodological constraints, changes in concept formulation and operationalization, and contradictions across findings have all made it difficult to draw firm conclusions regarding the predictive power of these factors. Second, the difficult measuring of home exercise adherence deserves special attention. As revealed in the previous reviews, the absence of verified and standardized methodologies is a significant methodological restriction in this field of research [ 23 , 34 ] , making it difficult to compare findings across studies. Moreover, noting that all studies included in the syntheses applied the cross-sectional design, it’s not possible to make conclusions about causal effects. Longitudinal studies are strongly recommended to draw definitive causal effects and confirm the presence or absence of associations. Lastly, only published full-text English language publications were considered, which may have created a publication bias given that unpublished studies may be more likely to have reported different findings. It might also be argued that the review did not consider differences in adherence metrics between studies sufficiently. Implications for Research and Practice In terms of research, further studies could be conducted to determine the nature of the relationships between HEPA and each of the five factors identified as consistent predictors, i.e., whether there are specific groups of parents or circumstances for which these predictors are especially strong, and whether other factors mediate or moderate the relationship. In conjunction with the expanding body of work on behaviour modification techniques [48] , these findings may assist to guide the most effective approaches to enhance HEPA. With knowledge suggesting the most significant factors of adherence behaviour targets in this context, the right choice of behaviour modification approaches for implementation in these interventions might be guided. Lastly, future research should seek to resolve the methodological constraints that have been identified in the current review, specifically concerns with home-exercise adherence monitoring to give more substantial evidence for predictors of HEPAs. In terms of practice, the review's findings have implications for practitioners implementing HEP programs with parents of C-CP. Considering that stronger parental self-efficacy, high knowledge, and ability to perform the exercises, low perceived barriers, social support and therapist guidance, high gross motor function, and low psychological distress tend to predict higher HEPAs, assessing these domains beforehand may uncover any risk factors for poor adherence. These findings give significant insights into how therapists and other stakeholders working with parents of C-CP may take a more active role in protecting against the alarming rate of HEP non-adherence by ensuring that appropriate assistance is in place or prioritizing currently accessible help. Priority areas should be reinforcing guidance of health professionals to parents, strong peer support networks, psychological support, and training of the parents to increase high self-efficacy, high knowledge, and ability to promote HEPA. Conclusion This systematic review highlighted that the factors affecting HEPA among parents of C-CP are in three main categories such as child-related factors (gross motor function), caregiver-related factors (education level, depression, and anxiety, stress, emotional exhaustion, high self-efficacy, high knowledge and ability, and low perception of the barriers, and social support), and therapist’s guidance and advice (amount of exercise prescribed, exercises that improve outcomes, exercise without adverse effects, and physiotherapist’s support). Knowing and assessing these factors gives researchers and practitioners more options for improving adherence through intervention design and practices aimed at strengthening facilitators and reducing obstacles to adherence. The analysis also revealed that the determinants of HEPA are still not completely understood. The current review has recommended avenues for future research by highlighting inconsistent findings and methodological shortcomings. Declarations Disclosure statement This manuscript is an abridged version of a chapter contributing to the first author’s thesis (not yet submitted). Funding Not applicable Conflict of interests All authors declare no conflict of interest. Data availability statement Data sharing is not applicable to this article as no new data were created or analysed in this study. Ethical statement Not applicable Authors’ contribution The authors have contributed equally to this manuscript. References Beckers, Geijen MME, Kleijnen J, A A Rameckers E, L A P Schnackers M, J E M Smeets R, et al. Feasibility and effectiveness of home-based therapy programmes for children with cerebral palsy: a systematic review. BMJ Open [Internet] 2020;10(10):e035454. Available from: https://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2019-035454 Sadowska M, Sarecka-Hujar B, Kopyta I. 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Using multivariate statistics. pearson Boston, MA; 2013. Başaran A, Karadavut KI, Üneri ŞÖ, Balbaloǧlu Ö, Atasoy N. Serebral palsili çocuklarin bakicilarinin ev egzersiz programina uyumlari. Turkiye Fiziksel Tip ve Rehabilitasyon Dergisi 2014;60(2):85–91. Medina-Mirapeix F, Lillo-Navarro C, Montilla-Herrador J, Gacto-Sánchez M, Franco-Sierra MA, Escolar-Reina P. Predictors of parents’ adherence to home exercise programs for children with developmental disabilities, regarding both exercise frequency and duration: A survey design. Eur J Phys Rehabil Med 2017;53(4):545–55. Bollen JC, Dean SG, Siegert RJ, Howe TE, Goodwin VA. A systematic review of measures of self-reported adherence to unsupervised home-based rehabilitation exercise programmes, and their psychometric properties. BMJ Open 2014;4(6):e005044–e005044. Lillo-Navarro C, Montilla-Herrador J, Escolar-Reina P, Oliveira-Sousa S, García-Vidal J, Medina-Mirapeix F. 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Tahayneh M, Humayra S, Fall AA, Rosland H, Amro A, Mohammed A, et al. Factors affecting mother’s adherence towards cerebral palsy home exercise program among children at hebron and bethlehem, Palestine. International Journal of Pharmaceutical Research 2020;12(4):1019–24. Tétreault S, Parrot A, Trahan J. Home activity programs in families with children presenting with global developmental delays: evaluation and parental perceptions. International Journal of Rehabilitation Research 2003;26(3):165–73. Demeke ZD, Assefa YA, Abich Y, Chala MB. Home-based therapy and its determinants for children with cerebral palsy, exploration of parents’ and physiotherapists’ perspective, a qualitative study, Ethiopia. PLoS One 2023;18(2):e0282328. Lillo-Navarro C, Medina-Mirapeix F, Escolar-Reina P, Montilla-Herrador J, Gomez-Arnaldos F, Oliveira-Sousa SL. Parents of children with physical disabilities perceive that characteristics of home exercise programs and physiotherapists’ teaching styles influence adherence: A qualitative study. J Physiother2015;61(2):81–6. Tipping CJ, Scholes RL, Cox NS. A qualitative study of physiotherapy education for parents of toddlers with cystic fibrosis. Journal of Cystic Fibrosis 2010;9(3):205–11. McConnell D, Parakkal M, Savage A, Rempel G. Parent-mediated intervention: adherence and adverse effects. Disabil Rehabil 2015;37(10):864–72. Novak I, Berry J. Home Program Intervention Effectiveness Evidence. Phys Occup Ther Pediatr 2014;34(4):384–9. Riquelme I, Cifre I, Montoya P. Are physiotherapists reliable proxies for the recognition of pain in individuals with cerebral palsy? A cross sectional study. Disabil Health J 2015;8(2):264–70. Faithfull S. The concept of cure in cancer care. Eur J Cancer Care (Engl) 1994;3(1):12–7. Michie S, Johnston M, Francis J, Hardeman W, Eccles M. From theory to intervention: mapping theoretically derived behavioural determinants to behaviour change techniques. Applied psychology 2008;57(4):660–80. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 12 Jun, 2024 Read the published version in PLOS ONE → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3079847","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":211522030,"identity":"bf169737-5446-450a-aeb6-2d9b5faea582","order_by":0,"name":"Japhet Niyonsenga","email":"","orcid":"","institution":"University of Parma","correspondingAuthor":false,"prefix":"","firstName":"Japhet","middleName":"","lastName":"Niyonsenga","suffix":""},{"id":211522033,"identity":"80e617ea-9ac5-4a19-89d4-d68c29648c2a","order_by":1,"name":"Athanasie Bugenimana","email":"","orcid":"","institution":"University of 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Background","content":"\u003cp\u003eCP is the largest diagnostic group treated in paediatric rehabilitation.\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e Cerebral palsy (CP) is a spectrum of motor development problems caused by persistent damage to the immature brain \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. The most frequent CP manifestations are deficits in sensory, communicative, cognitive, and musculoskeletal functioning that may severely limit the autonomy of children in their daily life.\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e Social participation, independence, and self-efficacy are restricted in children with CP, and about 60% of them have problems with the effective use of the arm and hand during reach, grasp, release, and manipulation of objects resulting in limitations in the performance of daily activities. \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e CP has common comorbidities such as epilepsy, standing at 35%-66.36% \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e, speech impairment (43.5%), visual impairment (25%-58%),\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e and cognitive impairment (24%).\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAccording to data from national cerebral palsy registries and population-based research in Europe, Australia, and the United States, the prevalence of CP is around 1.8\u0026ndash;2.3% per 1000 children \u003csup\u003e[\u003cspan additionalcitationids=\"CR9\" citationid=\"CR9\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. In contrast to the high-income countries, the prevalence of CP in Africa might reach up to 2\u0026ndash;10 per 1000 live births \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. While the main factors of CP in high-income countries are premature or low birth weight, \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e in Africa the major contributors are birth asphyxia, kernicterus, central nervous system infections and congenital and neonatal infections which are more easily preventable.\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAlthough the consequences of CP are permanent, early intervention programs have been shown to increase children\u0026rsquo;s independence and quality of life, especially when applied between the ages of birth and five, when neuroplasticity is at its greatest.\u003csup\u003e[\u003cspan additionalcitationids=\"CR15\" citationid=\"CR15\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e Early intervention allows C-CP to reinforce their remaining potential abilities by tackling their initial movement limitations. Besides professional intervention, the efficacy of rehabilitation depends on consistent, proper home exercise programs (HEP). HEP is a kind of treatment extension in which, in a paediatric context, a medical professional trains parents or caregivers on how to carry out the recommended program at home and between physical therapy visits.\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTo achieve an effective outcome, the HEP frequently accounts for 50\u0026ndash;80% of total therapy received by children with CP (C-CP).\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e The positive effects of HEP are not limited to children as, according to Novak, it can increase parental satisfaction \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. Moreover, HEP is important for rural families since it saves time and money while also involving parents in treatment decisions and allowing them to select what is best for their child.\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eNevertheless, Adherence to HEP (AHEP) in rehabilitation is a significant problem. The rate of non-adherence is estimated to range from 50\u0026ndash;66%\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e and it is expected to be significantly higher in poor-resource settings.\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e Parental non-adherence was reported to be the primary reason for treatment failure in long-term paediatric diseases\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e and it appears to be related to unnecessary and harmful changes in the treatments proposed by health professionals. Given this, a systematic review to explore the factors determining parental adherence/compliance to HEP is needed. In a recent systematic review on predictors of adult patients\u0026rsquo; adherence to home-based physical therapies, authors concluded that intention to engage in home-based physical therapy, self-motivation, self-efficacy, previous adherence to exercise-related behaviours and social support were robust predictors of adherence.\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e Similarly, another systematic review on barriers to treatment adherence in physiotherapy outpatient clinics, showed that poor treatment adherence, in general, was associated with low levels of physical activity in previous weeks, low self-efficacy, depression, anxiety, helplessness, poor social support, greater perceived number of barriers to exercise and increased pain levels during exercise among muscle-skeleton physiotherapy patients.\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eHowever, very little attention has so far been paid to the factors influencing the AHEP among parents of C-CP and no systematic review has been conducted to date. With this research gap in sight, the presented study was designed to provide an overview of the factors that influence parents\u0026rsquo; compliance with HEP for their C-CP as one of the robust rehabilitation strategies leading to the best clinical outcomes. Identification of barriers may help clinicians identify parents at risk of non-adherence and suggest methods to reduce the impact of those barriers thereby maximising adherence.\u003c/p\u003e"},{"header":"2. Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study design\u003c/h2\u003e \u003cp\u003eThis systematic review follows the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA). The PRISMA guidelines provide items informed by empirical research for systematic reviews and meta-analyses.\u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Search strategy and selection criteria\u003c/h2\u003e \u003cp\u003eThe sources of information that were used are Medline through PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINHAL), PsycINFO, and EMBASE. The search strategies for this review were established by applying Boolean operators to connect the descriptors. The descriptors were derived using a keyword and Mesh terms search (in PubMed) in each database's metadata system. The search terms were specially designed for the relevant database and comprised: terms relating to home exercise programs (e.g. 'exercise\\therapy', 'physiotherapy', 'home physiotherapy', 'home exercises', 'rehabilitation exercises'); terms concerning adherence (e.g. 'adherence', 'compliance', 'treatment compliance', 'parent engagement', \u0026lsquo;parent involvement\u0026rsquo;); terms referring to factors (e.g. 'barriers', \u0026lsquo;factors\u0026rsquo;, 'facilitators', determinants', \u0026lsquo;predictors') and terms referring to cerebral palsy (\u0026lsquo;cerebral palsy\u0026rsquo;, \u0026lsquo;neurodevelopmental disorders\u0026rsquo;, \u0026lsquo;quadriplegic\u0026rsquo;, \u0026lsquo;monoplegia\u0026rsquo; and \u0026lsquo;diplegia\u0026rsquo;).\u003c/p\u003e \u003cp\u003eTwo separate researchers searched (JN, BA). A third reviewer (MN) facilitated decision-making when there were disagreements. Studies yielded by the search strategy were eligible for inclusion if (i) the concerned parents of children with CP younger than 18; (ii) The exercises were assisted by a caregiver and not done by the patient himself; and (iii) the articles were in English. Notably, studies that included both clinic and home-based exercise adherence data were included if home-based data were reported separately. We excluded the following: (i) review articles; (ii) studies addressing children without confirmation of a CP diagnosis; and (iii) studies not available in their entirety.\u003c/p\u003e \u003cp\u003eThe initial choice was determined using the Boolean association of descriptors, followed by reading the titles, summaries, and eventually the complete article. We imported all references into our Covidence database (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.covidence.org\u003c/span\u003e\u003cspan address=\"https://www.covidence.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) for deduplication against other sources and screening according to the same inclusion criteria. The number of articles detected in electronic databases and excluded articles were rigorously reported in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. After identifying pertinent papers, their reference lists were hand-searched for more relevant literature. The papers chosen were tabulated at the end of the selection process for data collection, tabulation, and analysis, as well as later data interpretation and description.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Data extraction and management\u003c/h2\u003e \u003cp\u003eStudy characteristics and outcome data were extracted by one reviewer using a pre-designed data extraction spreadsheet. The information extracted for analysis was divided into three categories: study data, data about children with CP, and data about the parents. The following study details were extracted: study title, author(s), publication year, country of study, study design, participant characteristics (\u003cb\u003ee.g\u003c/b\u003e., child\u0026rsquo;s age range, parents\u0026rsquo; mean age) and the measure of adherence to the home exercise program. If some of the articles did not contain all the data required for the review, we included the available data (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of the main study characteristics and the key findings\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eKey findings\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthors, year and titles\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSample details\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-adherence Rate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003echild\u0026rsquo;s age\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eConcept (and measure) of Adherence to HEP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnivariate analysis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMultiple regression analysis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eStudy quality (NOS/ CASP)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBAŞARAN et al. (2014). Adherence to Home Exercise Program among Caregivers of Children with Cerebral Palsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e147 parents (43.5% females, mean age [MA]\u0026thinsp;=\u0026thinsp;34.3), Turkey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u0026ndash;18 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eA self-designed questionnaire with three close-ended questions assessing adherence.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGross motor function classification system, OR\u0026thinsp;=\u0026thinsp;1.50, p\u0026thinsp;=\u0026thinsp;0.01),\u003c/p\u003e \u003cp\u003eEmotional exhaustion, OR\u0026thinsp;=\u0026thinsp;0.92, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001),\u003c/p\u003e \u003cp\u003eDepression and anxiety were significantly not associated with adherence.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNOS-7 stars\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlwhaibi et al. (2022). Factors Affecting Mothers\u0026rsquo; Adherence to Home Exercise Programs Designed for Their Children with Cerebral Palsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e109 parents (99 females, MA\u0026thinsp;=\u0026thinsp;33.7, Saudi Arabia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBelow 12 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAn adapted questionnaire composed of 17 items scored on a 5-point Likert scale.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSocial support, β\u0026thinsp;=\u0026thinsp;0.156, p\u0026thinsp;=\u0026thinsp;0.041.\u003c/p\u003e \u003cp\u003eHealth professionals\u0026rsquo; behaviour, β\u0026thinsp;=\u0026thinsp;0.268, p\u0026thinsp;=\u0026thinsp;0.026.\u003c/p\u003e \u003cp\u003eMother\u0026rsquo;s sense of unsureness, β= -0.306, p\u0026thinsp;=\u0026thinsp;0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNOS-8 stars\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLillo-Navarro et al. (2019). Factors Associated with Parents\u0026rsquo; Adherence to Different Types of Exercises in Home Programs for Children with Disabilities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e219 parents (85% female; MA\u0026thinsp;=\u0026thinsp;34.3), Spain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAdherence was assessed according to the prescribed dosage of the HEP on a 5-point Likert scale (1\u0026thinsp;=\u0026thinsp;never, to 5\u0026thinsp;=\u0026thinsp;always).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEducation level, OR\u0026thinsp;=\u0026thinsp;0.40, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003eChild inability to maintain sitting, OR\u0026thinsp;=\u0026thinsp;2.12, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05,\u003c/p\u003e \u003cp\u003eLow perception of barriers, OR\u0026thinsp;=\u0026thinsp;2.7, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e \u003cp\u003eHigh knowledge and ability, OR\u0026thinsp;=\u0026thinsp;5.68, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003eHigh self-efficacy\u0026thinsp;=\u0026thinsp;3.28, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eChild inability to maintain sitting, OR\u0026thinsp;=\u0026thinsp;2.65, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001,\u003c/p\u003e \u003cp\u003eLow perception of barriers, OR\u0026thinsp;=\u0026thinsp;2.52, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e \u003cp\u003eHigh knowledge and ability, OR\u0026thinsp;=\u0026thinsp;3.69, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001,\u003c/p\u003e \u003cp\u003eGiving information about evolution, OR\u0026thinsp;=\u0026thinsp;6.27,\u003c/p\u003e \u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.05; Justifying usefulness of exercises, OR\u0026thinsp;=\u0026thinsp;9.49, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Using the child as a model, OR\u0026thinsp;=\u0026thinsp;2.72, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05; Asking about adherence at home, OR\u0026thinsp;=\u0026thinsp;2.98, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Parents\u0026rsquo; high satisfaction with the care received, OR\u0026thinsp;=\u0026thinsp;1.71, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNOS-9 stars\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMEDINA-MIRAPEIX et al (2017). Predictors of parents\u0026rsquo; adherence to home exercise programs for children with developmental disabilities, regarding both exercise frequency and duration: a survey design\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e219 parents (8 males, 99 females; MA\u0026thinsp;=\u0026thinsp;34.3), Spain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5-6 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAdherence was assessed according to the prescribed dosage of the HEP on a five-point (1\u0026thinsp;=\u0026thinsp;never, to 5\u0026thinsp;=\u0026thinsp;always).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLow perception of barriers, OR\u0026thinsp;=\u0026thinsp;5.68, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e \u003cp\u003eHigh knowledge and ability, OR\u0026thinsp;=\u0026thinsp;2.18, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003eHigh self-efficacy\u0026thinsp;=\u0026thinsp;6.82, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003eSocial support, OR\u0026thinsp;=\u0026thinsp;2.04, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003eAge\u0026thinsp;\u0026lt;\u0026thinsp;2 years, OR\u0026thinsp;=\u0026thinsp;1.99, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05,\u003c/p\u003e \u003cp\u003eChild inability to sit, OR\u0026thinsp;=\u0026thinsp;2.23, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05,\u003c/p\u003e \u003cp\u003eIn treatment\u0026thinsp;\u0026lt;\u0026thinsp;2 years OR\u0026thinsp;=\u0026thinsp;2.3, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLow perception of barriers, OR\u0026thinsp;=\u0026thinsp;4.83, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; High self-efficacy, OR\u0026thinsp;=\u0026thinsp;6.67, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e \u003cp\u003eHigh knowledge and ability, OR\u0026thinsp;=\u0026thinsp;2.21, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e \u003cp\u003eSocial support, OR\u0026thinsp;=\u0026thinsp;2.97, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e \u003cp\u003eAge\u0026thinsp;\u0026lt;\u0026thinsp;2 years, OR\u0026thinsp;=\u0026thinsp;2.09, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003cp\u003eChild\u0026rsquo;s inability to walk, OR\u0026thinsp;=\u0026thinsp;3.02, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Information about progress, OR\u0026thinsp;=\u0026thinsp;3.75,\u003c/p\u003e \u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.05,\u003c/p\u003e \u003cp\u003eJustifying usefulness of exercises, OR\u0026thinsp;=\u0026thinsp;2.17, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003cp\u003eAdvising to insert HEP into daily, (OR\u0026thinsp;=\u0026thinsp;2.54, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003cp\u003eChecking skills, OR\u0026thinsp;=\u0026thinsp;2.21, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003eAsking about adherence at home, OR\u0026thinsp;=\u0026thinsp;2.20, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003cp\u003eParents\u0026rsquo; high satisfaction with the care received, OR\u0026thinsp;=\u0026thinsp;1.71, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNOS-9 stars\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRone-Adams et al. (2004). Stress and Compliance with a Home Exercise Program Among Caregivers of Children with Disabilities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66 parents, South Florida\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBelow 18 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eA self-designed questionnaire of six close-ended questions was used to assess HEP.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eThe level of stress (F\u0026thinsp;=\u0026thinsp;4.417, p\u0026thinsp;\u0026lt;\u0026thinsp;0.039, R\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.065).\u003c/p\u003e \u003cp\u003eParent and family problems (r\u0026thinsp;=\u0026thinsp;0.345, p\u0026thinsp;=\u0026thinsp;0.005).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNOS-6 stars\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSel et al., (2020). Parents of children with physical disabilities perceive that characteristics of home exercise programs and physiotherapists\u0026rsquo; teaching styles influence adherence: a qualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e155 parents, Turkey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u0026ndash;18 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28 items Validated Questionnaire measuring adherence.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDepression and anxiety (r=-0.405, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001),\u003c/p\u003e \u003cp\u003emedication use\u003c/p\u003e \u003cp\u003e(r=-0.233, p\u0026thinsp;=\u0026thinsp;0.003),\u003c/p\u003e \u003cp\u003eDevice use (r\u0026thinsp;=\u0026thinsp;0,741,\u003c/p\u003e \u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003cp\u003eHealth professional attitudes (r\u0026thinsp;=\u0026thinsp;0.221, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003cp\u003eGross motor function classification system, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01),\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNOS-7 stars\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTahayneh et al., (2020), Factors affecting mother\u0026rsquo;s adherence towards cerebral palsy home exercise program among children at hebron and bethlehem, Palestine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 mothers, \u003cb\u003ePalestine\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026ndash;3 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eA self-reported questionnaire was used to assess adherence on a 5-\u003c/p\u003e \u003cp\u003epoint Likert scale (5 strongly agree to 1 strongly disagree)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eThe socio-economic, work, age, education and marital of mothers were not associated with HEP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNOS-6 stars\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGmmash et al. (2021). Parental Adherence to Home Activities in Early Intervention for Young Children with Delayed Motor Development.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e446 participants (96% females), \u003cb\u003eUSA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot available\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eA self-reported questionnaire was used to assess adherence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTherapists\u0026rsquo; modelling of the activities (r\u0026thinsp;=\u0026thinsp;0.5, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), parent\u0026rsquo;s self-efficacy in the application of Home activity ([HA], r\u0026thinsp;=\u0026thinsp;0.6, p\u0026thinsp;\u0026lt;\u0026thinsp;.000), HA enjoyed by a child (r\u0026thinsp;=\u0026thinsp;0.5 p\u0026thinsp;\u0026lt;\u0026thinsp;.0001), HA appropriate for daily routines (r\u0026thinsp;=\u0026thinsp;0.7, p\u0026thinsp;\u0026lt;\u0026thinsp;.000), HA appropriate for daily routines (r\u0026thinsp;=\u0026thinsp;0.7, p\u0026thinsp;\u0026lt;\u0026thinsp;.000), HA appropriate for home environment (r\u0026thinsp;=\u0026thinsp;0.6, p\u0026thinsp;\u0026lt;\u0026thinsp;.000), HA includes child\u0026rsquo;s sibling and extended family (r\u0026thinsp;=\u0026thinsp;0.3, p\u0026thinsp;\u0026lt;\u0026thinsp;.000) were all significantly associated\u003c/p\u003e \u003cp\u003ewith adherence to HA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNOS-7 stars\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/sup\u003e. Compliance with home rehabilitation therapy by parents of children with disabilities in Jews and Bedouin in Israel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e193 participants, \u003cb\u003eIsrael\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79.2% of Jews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.6-6 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCompliance was measured by two questions from the validated questionnaire.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThe strongest factors significantly and positively associated with adherence to HEP were being Bedouin, parents\u0026rsquo; education, hopefulness, the belief that exercise will improve functioning, satisfaction with the services and socioeconomic status, whereas the intensity of questioning destiny reduced adherence.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNOS-7 stars\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/sup\u003e. \u003c/p\u003e \u003cp\u003eHome activity programs in families with children presenting with global developmental delays: evaluation and parental perceptions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 participants (90.3% females)\u003c/p\u003e \u003cp\u003e\u003cb\u003eCanada\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u0026ndash;8 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eA self-reported questionnaire.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eSocial support and negative feelings such as motivation, hope, confidence, being more realistic and being at ease and satisfied with the idea of HEP were positively associated with adherence. But adherence was inversely related to the difficulty to integrate exercise into daily life and negative feelings such as burden, guilt, and discouragement.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNOS-6 stars\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003c/sup\u003e. Investigation of parents' compliance in physical therapy at home with toddlers diagnosed with cerebral palsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63 parents (51% female)\u003c/p\u003e \u003cp\u003e\u003cb\u003eGreece\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026ndash;6 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eA self-reported questionnaire\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003esimple, comprehensible, fun exercises, therapeutic support from the physiotherapist, personal communication and understanding, training of the parents, and involvement of parents in physiotherapy improve adherence to HEP. However, fear of causing pain and negative parents\u0026rsquo; view of physiotherapy reduce adherence.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNOS-6 stars\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemeke et al., (2023). Home-based therapy and its determinants for children with cerebral palsy, exploration of parents\u0026rsquo; and physiotherapists\u0026rsquo; perspective, a qualitative study, Ethiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 participants (27\u0026ndash;39 years), Ethiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot available\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026ndash;4 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIndividual, face-to-face, and semi-structured interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eLow family support, limited recourse, lack of knowledge and poor attitude negatively affected adherence to home-based therapy.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCASP-10 stars\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003csup\u003e[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/sup\u003e. Parents of children with physical disabilities perceive that characteristics of home exercise programs and physiotherapists' teaching styles influence adherence: A qualitative study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 participants, Spain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.5-6 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFocus group discussion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eTwo key themes related to adherence were the characteristics of the HEP (the perceived effects of the exercises, their complexity, and the number of exercises undertaken) and the characteristics of the physiotherapist\u0026rsquo;s teaching style (when their physiotherapist tried to build parents\u0026rsquo; confidence in the exercises, helped the parents to incorporate the HEP into their daily routine, provided incentives and increased motivation).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCASP-10 stars\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e\u003cem\u003e2\u003c/em\u003e.5. Quality assessment\u003c/h2\u003e \u003cp\u003eThe Newcastle-Ottawa Scale adapted for cross-sectional studies was used to evaluate the methodological quality of the quantitative studies because all review studies were explicitly of this type.\u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e The scale rates evidence quality based on selection, comparability, and outcome, with stars assigned based on the NOS coding handbook. A maximum of five stars might be given for selection, two for comparability, and three for the outcome. The number of stars granted indicates the quality of the study.\u003c/p\u003e \u003cp\u003eThe Critical Appraisal Skills Programme Tool for Qualitative Research (CASP) was used to assess the quality of the qualitative studies included in the review. The tool consists of 10 criteria that evaluate a study's methodological rigour and validity.\u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e A rating approach was used to determine relative study quality.\u003csup\u003e[28]\u003c/sup\u003e Studies were classified as 'high quality' if they satisfied at least eight of the ten criteria, 'moderate quality' if they met 5\u0026ndash;7 of the criteria, and 'poor quality' if they met four or fewer.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Data synthesis\u003c/h2\u003e \u003cp\u003eThe first plan was to do a meta-analysis. Unfortunately, there was little data provided in the studies found by this review, and the data that was gathered was inconsistent in terms of measures employed (7 out of 9 were self-designed) and analysis undertaken. As such, it was decided to conduct a narrative synthesis rather than a meta-analysis to synthesize the data in the most meaningful way possible, guided by the concepts described by Popay and colleagues.\u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e A narrative synthesis approach was used to describe, compare, and combine findings from multiple studies.\u003c/p\u003e \u003cp\u003eThis method concentrates on textual summaries and results descriptions with the primary goal of \"telling the tale \u0026ldquo;of the findings from the included research.\u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e The elements of this process in this review included: developing a preliminary synthesis to organize the findings from the included studies; exploring relationships within this data to understand and explain patterns or differences; and assessing the robustness of the synthesis by considering the strength, quality, and generalizability of the included data.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Characteristics of included studies.\u003c/h2\u003e \u003cp\u003eThe search resulted in 432 records. After deduplication, a total of 342 titles and abstracts were screened, resulting in 326 irrelevant records. The remaining 16 records were full texts assessed for eligibility, of which three did not meet the eligibility criteria. The search resulted in 13 records. The flow chart of the literature search is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. There were 13 corresponding and last authors contacted to provide any related studies. Of these authors, 8 (59%) responded with either a suggestion or no additions at all, resulting in two additional records already included in the 13 records.\u003c/p\u003e \u003cp\u003eEleven quantitative and two qualitative studies addressing the factors influencing parents’ HEPA were included in the final review (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Three studies were conducted in Spain, two in Turkey, two in the USA, and one in each of these countries: Saudi Arabia, Ethiopia, Israel and Palestine. Three studies were published between 2000 and 2005, and the remaining 10 studies were published between 2013 and 2023. Though all studies' samples were mixed, sample participants were predominantly female, with percentages ranging from 51–99% of the total sample. Sample sizes also varied greatly ranging from 17 to 446 participants. The mean age for all studies was closely 34 years old for parents whereas the age range for children was 0.5–18 years. All adherence measures included participant self-report. The adherence results were often dichotomized into 'adherent' and 'non-adherent' individuals for analysis or expressed as a percent of the suggested exercise done.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Quality assessment of the included articles.\u003c/h2\u003e \u003cp\u003eFor the appraisal of the quantitative studies, two studies were awarded 9 stars, one study was awarded 8 stars, four were awarded 7 stars, one was awarded 8 stars and the rest four studies were awarded seven stars (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The biggest concern discovered during the quality assessment was that all studies employed convenience sampling, meaning that participants may not represent the research population. Except for one study,\u003csup\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e the rest did not use power analyses or sample size estimates to support their sample size. Although there are no universal guidelines for determining the optimal sample size for multivariate analyses, a small sample size may lead to less confidence in the results.\u003csup\u003e[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/sup\u003e Although considering the kind of target population, the convenient sample is reasonable, the authors would adapt appropriate analysis according to the quality of their sample. Therefore, variations in the study sample sizes may explain inconsistencies in significant findings for a specific factor. Furthermore, response rates were low throughout the studies, with no description of the characteristics of non-responders provided. Therefore, determining how representative the participants were challenging.\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e Parents who were most adherent to HEP may have been more willing to participate in the research because they saw it as relevant and valuable. Conversely, non-adherent parents could prefer not to talk about it and not take part in the research.\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eNotably, non-validated measures of different concepts were often used and the scale reliability evaluations for the given sample were not always conducted \u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/sup\u003e or did not always indicate adequate reliability. Moreover, all studies employed self-report methods to assess HEPA and its associated factors, which rely on individuals properly remembering and reporting their exercises. Therefore, individuals are vulnerable to social desirability and memory biases, which can lead to overestimation of adherence. This agrees with the findings of a previous systematic review of self-report measures of general adherence to home-based rehabilitation programs which showed that all 61 identified measures lacked psychometric validity.\u003csup\u003e[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/sup\u003e The current review found that factors such as social support and self-efficacy were also assessed by a single item derived from their related validated scales that may not effectively assess target concepts.\u003csup\u003e[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/sup\u003e Other research attempted to address these concerns by developing new measures based on existing scales or theories in the scientific literature \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/sup\u003e or by pre-testing and piloting the scales.\u003c/p\u003e \u003cp\u003eOn the other hand, two qualitative studies included in the review were of high quality in terms of their approach to participant recruitment, data collection and analysis (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). All these studies adequately considered the role of the researcher and how they might influence the study results.\u003c/p\u003e \u003cp\u003e \u003cb\u003e“\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e: \u003cb\u003eSummary of the main study characteristics and the key findings\u003c/b\u003e\u003cb\u003e”\u003c/b\u003e should be here.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Factors influencing the adherence to home exercise programs among parents of children with cerebral palsy.\u003c/h2\u003e \u003cp\u003eOur analysis identified several psychosocial and situational factors that have been considered in the literature to date, and were grouped into four conceptually related categories: Child related factors, caregiver-related factors, and therapist guidance and advice. We relied on the descriptive information supplied in the original articles to address our secondary research aim of identifying the specific factors that are perceived to be beneficial or detrimental in adhering to HEP among parents of C-CP.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e3.3.1 Child-related factors of HEPA\u003c/h2\u003e \u003cp\u003e \u003cb\u003eGross motor function\u003c/b\u003e \u003c/p\u003e \u003cp\u003eFour quantitative studies showed an inverse relationship between gross motor function and HEPA \u003csup\u003e[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/sup\u003e. These studies evidenced that parents’ adherence appeared to be higher when the gross motor function was low.\u003c/p\u003e \u003cp\u003e \u003cb\u003eChild age, gender, and weight\u003c/b\u003e \u003c/p\u003e \u003cp\u003eFour quantitative studies conducted showed mixed findings on the association between child age and HEPA.\u003csup\u003e[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/sup\u003e While two studies revealed no associations between child age and HEPA,\u003csup\u003e[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/sup\u003e one study showed a positive association, indicating that parents with younger children were more likely to adhere.\u003csup\u003e[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/sup\u003e Two separate quantitative studies found no associations between the child’s gender, \u003csup\u003e[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/sup\u003e the child’s weight \u003csup\u003e[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/sup\u003e and HEPA.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e3.3.2. Caregiver-related factors of HEPA\u003c/h2\u003e \u003cp\u003e \u003cb\u003eEducation level, age, and marital status\u003c/b\u003e \u003c/p\u003e \u003cp\u003eFour quantitative studies have consistently revealed that mothers’ educational status was positively related to adherence.\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003c/sup\u003e These studies suggested that parental education helps parents feel less anxious about injuring or causing harm to their children. Further, the association between the caregiver’s age and HEPA was inconsistent. \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e39\u003c/span\u003e]\u003c/sup\u003e Only one study out of four indicated significant positive associations \u003csup\u003e[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/sup\u003e. There was also strong evidence that marital status \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/sup\u003e and the household number of children were not related to HEPA among parents.\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eDepression and Anxiety\u003c/b\u003e \u003c/p\u003e \u003cp\u003eTwo quantitative studies showed significant negative associations between parental depression and anxiety, and HEPA \u003csup\u003e[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003c/sup\u003e and were complemented by one qualitative study.\u003csup\u003e[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/sup\u003e These studies strongly evidenced that the severity of depression and anxiety symptoms were salient risks of non-HEPA. The only study where this association was not significant \u003csup\u003e[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/sup\u003e is characterized by a weak methodological design (Table). This weakness can be traced to the sample predominated by fathers (51%) who are not usually involved in HEP \u003csup\u003e[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e39\u003c/span\u003e]\u003c/sup\u003e and a non-validated self-report measure of adherence.\u003csup\u003e[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eStress and emotional burden/exhaustion\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThree articles highlighted that mothers’ sense of insecurity and doubts about their ability to complete exercises and burnout level,\u003csup\u003e[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/sup\u003e level of stress, and family problems \u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e were detrimental to parents’ HEPA.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePositive Cognitions\u003c/b\u003e \u003c/p\u003e \u003cp\u003eOf 13 studies included in this review, five quantitative studies have investigated cognitive factors such as high self-efficacy, high knowledge and ability, and low perception of the barriers that enhance parents’ HEPA.\u003csup\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/sup\u003e According to these studies, all these factors are positively correlated with HEPA.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSocial support\u003c/b\u003e \u003c/p\u003e \u003cp\u003eSocial support is the perception and experience that one is taken care of, that supportive resources are available from others, and, most commonly, that one is part of a social network that is supportive. Although social support may involve several types of support, it was only assessed through one item and identified as a potential factor enhancing the likelihood of HEPA in four quantitative studies evidenced.\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/sup\u003e The same result was reported in one of the qualitative studies included in the review \u003csup\u003e[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e41\u003c/span\u003e]\u003c/sup\u003e which was carried out through individual, face-to-face, and semi-structured interviews.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFamily Income and\u003c/b\u003e \u003cb\u003eequipment\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThere were mixed findings on the positive association between family income and adherence in five quantitative studies, with some studies indicating significant positive associations\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/sup\u003e and no significance.\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e39\u003c/span\u003e]\u003c/sup\u003e Also, the availability of the home equipment necessary for the exercises did not affect the level of parental HEPA.\u003csup\u003e[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/sup\u003e Despite few studies conducted, these results indicate that parents do not any special equipment to adhere to HEPA.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e3.3.3 Therapist Guidance and Advice\u003c/h2\u003e \u003cp\u003e \u003cb\u003eAmount of exercise\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe number of exercises prescribed by health professionals was investigated by two studies: a quantitative study \u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e and a qualitative study.\u003csup\u003e[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e42\u003c/span\u003e]\u003c/sup\u003e These studies highlighted that the more exercises prescribed, the less likely parents were to adhere to the recommendations. Healthcare professionals thus, need to take care of this while designing HEP for parents of C-CP.\u003c/p\u003e \u003cp\u003e \u003cb\u003eExercises that improve outcomes\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThere were consistent findings on the positive associations between parental perception of the benefits and efficacy of exercise and HEPA in five quantitative studies \u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/sup\u003e and complemented by one qualitative study \u003csup\u003e[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e42\u003c/span\u003e]\u003c/sup\u003e which may support the generalisability of the findings. In this case, it is thought that parents are highly motivated and hopeful when their children’s conditions improve thanks to exercises performed.\u003csup\u003e[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eExercise without adverse effects on Children\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe perceived adverse effects or pain of the exercises on C-CP were found to be negatively related to HEPA in two quantitative studies.\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003c/sup\u003e This finding was complemented by the qualitative study, which recognized pain as detrimental to HEPA.\u003csup\u003e[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e42\u003c/span\u003e]\u003c/sup\u003e Therefore, it can be concluded that the presence of pain or adverse effects during exercise plays a crucial role in executing and adhering to HEP.\u003c/p\u003e \u003cp\u003e \u003cb\u003eEasy and enjoyable exercises\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThree quantitative studies continually reported enjoyable and easy exercises \u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/sup\u003e as potential factors of HEPA, demonstrating a largely positive relationship in multivariate analyses. This was also confirmed in one qualitative study.\u003csup\u003e[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e42\u003c/span\u003e]\u003c/sup\u003e As such, an effective home treatment program should contain easy, understandable, and entertaining exercises that are suited to daily activities.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePhysiotherapist’s Support\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe relationship between support from the physiotherapist and HEPA was investigated in seven quantitative studies \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/sup\u003e and a qualitative one.\u003csup\u003e[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e42\u003c/span\u003e]\u003c/sup\u003e There was mounting and consistent evidence that parents were more likely to adhere to home exercises when they were satisfied with the care from their therapist \u003csup\u003e[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan additionalcitationids=\"CR36\" citationid=\"CR36\" class=\"CitationRef\"\u003e35\u003c/span\u003e–\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/sup\u003e and informed about the progress and clarification of doubts.\u003csup\u003e[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/sup\u003e Further, parents who were motivated by the therapist advised to insert exercises into daily routines, assessed their skills, or asked about adherence at home by their therapists were more likely to comply with home exercises.\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e42\u003c/span\u003e]\u003c/sup\u003e Yet, some authors \u003csup\u003e[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e43\u003c/span\u003e]\u003c/sup\u003e have highlighted the risk that this follow-up may lead to stress and feelings of guilt in parents. Similarly, Lillo-Navarro and his colleagues \u003csup\u003e[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/sup\u003e suggested that healthcare providers must be aware of this circumstance to be perceived as a source of assistance rather than a judgemental bystander.\u003c/p\u003e \u003cp\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe specificity of this systematic review lies in the fact that it is focused on paediatric home-based rehabilitation strategy and the indispensable role played by caregivers in this process. The prior reviews emphasized factors of adherence to home-based therapies\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e and clinical-based therapies\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e among adult patients, but none have been conducted specifically for paediatric patients. In the previous reviews, the predictors of adherence to home physical therapy by adults sufficiently self-reliant to be able to participate in the research are assessed from the patient's own experience. In those cases, poor treatment adherence, in general, was found to be associated with low levels of physical activity in previous weeks, poor social support, low self-efficacy, greater perceived number of barriers to exercise, helplessness, self-motivation, increased pain levels,\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e depression, and anxiety during exercise among adult muscle-skeleton physiotherapy patients.\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eTo the best of our knowledge, this is the first systematic review that objectively assesses the factors influencing adherence to home exercise programs among mothers of C-CP. The results of the quality assessment of 13 studies included in this review showed that most of them were of high quality. We found strong evidence of three categories of factors influencing HEPA: child-related factors (gross motor function), caregiver-related factors (education level, depression, and anxiety, stress, emotional exhaustion, high self-efficacy, high knowledge and ability, and low perception of the barriers, and social support), and therapist’s guidance and advice (amount of exercise prescribed, exercises that improve outcomes, exercise without adverse effects, and physiotherapist’s support). Each of these factors is important in the paediatric rehabilitation of C-CP not so much because of their direct impact on the patient but mainly because they contribute to reinforcing or counteracting the mother's level of adhesion.\u003c/p\u003e\u003cp\u003eWhen faced with patients with severely reduced autonomy, be they children, the elderly or the severely disabled, adherence to care can only depend on the adherence of the caregiver him/herself. But this caregiver is not simply a transmitter of deliveries or an executor of orders. He/she too has own struggles, fears, hopes, and convictions. Consistently, one unique and interesting factor that emerged in the current review is the physiotherapist’s guidance and advice. It is fair to believe that when therapists focus on enhancing parents' knowledge and abilities by offering information, \u003csup\u003e[\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e44\u003c/span\u003e]\u003c/sup\u003e explaining the use of exercises, \u003csup\u003e[\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e45\u003c/span\u003e]\u003c/sup\u003e and using the child as an example improves adherence. It further emerged that when parents were given information about the benefits of exercise, it greatly boosted their chances of adhering to HEP. This might be owing to a better knowledge of a cause-effect relationship, which improves adherence rates, particularly for activities that parents find more difficult to complete.\u003c/p\u003e\u003cp\u003eIt was also found that mothers may have higher adherence to some types of exercises than others. These findings are in concordant with those reported previously showing that most parents see flexibility exercises as unpleasant and complicated activities.\u003csup\u003e[\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e46\u003c/span\u003e]\u003c/sup\u003e As such, while planning treatments with families, therapists should consider their effect on adherence to these sorts of exercises.\u003c/p\u003e\u003cp\u003eWhile the factor represented by gross motor function is a given condition that does not depend on subsequent interventions, the ability to perform HEPA consistently can substantially improve patients' living conditions by recovering parts of the functions impaired by paralysis. With paediatric patients, the performance of HEPA is strictly dependent on the caregiver's adherence to the physiotherapist's recommendations.\u003c/p\u003e\u003cp\u003eHaving a child with a disability place parents in having to accept an 'unacceptable' situation. Parents are likely to be affected by their child's difficulties and suffering and are therefore more at risk of developing psychosocial problems that may in turn affect the well-being and rehabilitation process of children with cerebral palsy. Thus, the effectiveness of the physiotherapist's prescriptions will depend on the latter's ability to build a relationship of trust with the caregiver.\u003c/p\u003e\u003cp\u003eThe results that emerged from this review attempted to bridge the literature gap by providing comprehensive and updated literature on the factors affecting HEPA. Our findings emphasised the integration of the concept of “care “to create a more favourable condition to achieve the cure rather than a sole consideration of the concept of “cure” which is often used in healthcare practices without thought to the social, cultural, and psychological implications of its meaning.\u003csup\u003e[\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e47\u003c/span\u003e]\u003c/sup\u003e As such, the \"cure versus care\" dichotomy which states that family members believe it is the responsibility of professionals to cure their patient while they are responsible for providing care, captures the natural preference of families in Rwandan culture to be involved in the care of their children with cerebral palsy.\u003c/p\u003e\u003cp\u003e \u003cb\u003eStudy strengths and limitations\u003c/b\u003e \u003c/p\u003e\u003cp\u003eThis review was rigorous and used a strong methodological approach to discover, appraise, and synthesize significant findings. The search parameters were intentionally broad to locate research examining a wide variety of factors that may impact HEPA among parents of children with cerebral palsy. It also used a robust quality criteria tool to assess the articles included in the synthesis.\u003c/p\u003e\u003cp\u003eNevertheless, our findings should be interpreted considering the methodological limitations of included studies and the review itself. First, a small number of studies exploring several factors, studies' methodological constraints, changes in concept formulation and operationalization, and contradictions across findings have all made it difficult to draw firm conclusions regarding the predictive power of these factors. Second, the difficult measuring of home exercise adherence deserves special attention. As revealed in the previous reviews, the absence of verified and standardized methodologies is a significant methodological restriction in this field of research \u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/sup\u003e, making it difficult to compare findings across studies.\u003c/p\u003e\u003cp\u003eMoreover, noting that all studies included in the syntheses applied the cross-sectional design, it’s not possible to make conclusions about causal effects. Longitudinal studies are strongly recommended to draw definitive causal effects and confirm the presence or absence of associations. Lastly, only published full-text English language publications were considered, which may have created a publication bias given that unpublished studies may be more likely to have reported different findings. It might also be argued that the review did not consider differences in adherence metrics between studies sufficiently.\u003c/p\u003e\u003cp\u003e \u003cb\u003eImplications for Research and Practice\u003c/b\u003e \u003c/p\u003e\u003cp\u003eIn terms of research, further studies could be conducted to determine the nature of the relationships between HEPA and each of the five factors identified as consistent predictors, i.e., whether there are specific groups of parents or circumstances for which these predictors are especially strong, and whether other factors mediate or moderate the relationship. In conjunction with the expanding body of work on behaviour modification techniques \u003csup\u003e[48]\u003c/sup\u003e, these findings may assist to guide the most effective approaches to enhance HEPA. With knowledge suggesting the most significant factors of adherence behaviour targets in this context, the right choice of behaviour modification approaches for implementation in these interventions might be guided. Lastly, future research should seek to resolve the methodological constraints that have been identified in the current review, specifically concerns with home-exercise adherence monitoring to give more substantial evidence for predictors of HEPAs.\u003c/p\u003e\u003cp\u003eIn terms of practice, the review's findings have implications for practitioners implementing HEP programs with parents of C-CP. Considering that stronger parental self-efficacy, high knowledge, and ability to perform the exercises, low perceived barriers, social support and therapist guidance, high gross motor function, and low psychological distress tend to predict higher HEPAs, assessing these domains beforehand may uncover any risk factors for poor adherence. These findings give significant insights into how therapists and other stakeholders working with parents of C-CP may take a more active role in protecting against the alarming rate of HEP non-adherence by ensuring that appropriate assistance is in place or prioritizing currently accessible help. Priority areas should be reinforcing guidance of health professionals to parents, strong peer support networks, psychological support, and training of the parents to increase high self-efficacy, high knowledge, and ability to promote HEPA.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis systematic review highlighted that the factors affecting HEPA among parents of C-CP are in three main categories such as child-related factors (gross motor function), caregiver-related factors (education level, depression, and anxiety, stress, emotional exhaustion, high self-efficacy, high knowledge and ability, and low perception of the barriers, and social support), and therapist’s guidance and advice (amount of exercise prescribed, exercises that improve outcomes, exercise without adverse effects, and physiotherapist’s support). Knowing and assessing these factors gives researchers and practitioners more options for improving adherence through intervention design and practices aimed at strengthening facilitators and reducing obstacles to adherence. The analysis also revealed that the determinants of HEPA are still not completely understood. The current review has recommended avenues for future research by highlighting inconsistent findings and methodological shortcomings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDisclosure statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis manuscript is an abridged version of a chapter contributing to the first author’s thesis (not yet submitted).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare no conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData sharing is not applicable to this article as no new data were created or analysed in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contribution\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have contributed equally to this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBeckers, Geijen MME, Kleijnen J, A A Rameckers E, L A P Schnackers M, J E M Smeets R, et al. Feasibility and effectiveness of home-based therapy programmes for children with cerebral palsy: a systematic review. BMJ Open [Internet] 2020;10(10):e035454. Available from: https://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2019-035454\u003c/li\u003e\n \u003cli\u003eSadowska M, Sarecka-Hujar B, Kopyta I. \u0026lt;p\u0026gt;Cerebral Palsy: Current Opinions on Definition, Epidemiology, Risk Factors, Classification and Treatment Options\u0026lt;/p\u0026gt;. Neuropsychiatr Dis Treat 2020;Volume 16:1505\u0026ndash;18.\u003c/li\u003e\n \u003cli\u003eRosenbaum P, Paneth N, Leviton A, Goldstein M, Bax M, Damiano D, et al. A report: the definition and classification of cerebral palsy April 2006. Dev Med Child Neurol Suppl 2007;109:8\u0026ndash;14.\u003c/li\u003e\n \u003cli\u003ePennington L. Cerebral palsy and communication. Paediatr Child Health 2008;18(9):405\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eChaudhary S, Bhatta NK, Poudel P, Agrawal J, Kalawar RPS, Jayswal JP. 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Effects of a training programme of functional electrical stimulation (FES) powered cycling, recreational cycling and goal-directed exercise training on children with cerebral palsy: a randomised controlled trial protocol. BMJ Open 2019;9(6):e024881.\u003c/li\u003e\n \u003cli\u003eJohnson RW, Williams SA, Gucciardi DF, Bear N, Gibson N. Evaluating the effectiveness of home exercise programmes using an online exercise prescription tool in children with cerebral palsy: protocol for a randomised controlled trial. BMJ Open 2018;8(1):e018316.\u003c/li\u003e\n \u003cli\u003eNovak I. Parent Experience of Implementing Effective Home Programs. Phys Occup Ther Pediatr 2011;31(2):198\u0026ndash;213.\u003c/li\u003e\n \u003cli\u003eAlwhaibi RM, Omer AB, Khan R. Factors Affecting Mothers\u0026rsquo; Adherence to Home Exercise Programs Designed for Their Children with Cerebral Palsy. Int J Environ Res Public Health [Internet] 2022;19(17):10792. Available from: https://www.mdpi.com/1660-4601/19/17/10792\u003c/li\u003e\n \u003cli\u003eArgent R, Daly A, Caulfield B. Patient Involvement With Home-Based Exercise Programs: Can Connected Health Interventions Influence Adherence? JMIR Mhealth Uhealth [Internet] 2018;6(3):e47. Available from: https://mhealth.jmir.org/2018/3/e47/\u003c/li\u003e\n \u003cli\u003eRone-Adams SA, Stern DF, Walker V. Stress and Compliance with a Home Exercise Program Among Caregivers of Children with Disabilities. Pediatric Physical Therapy [Internet] 2004;16(3):140\u0026ndash;8. Available from: http://journals.lww.com/00001577-200401630-00002\u003c/li\u003e\n \u003cli\u003eEssery R, Geraghty AWA, Kirby S, Yardley L. Predictors of adherence to home-based physical therapies: a systematic review. Disabil Rehabil 2017;39(6):519\u0026ndash;34.\u003c/li\u003e\n \u003cli\u003eJack K, McLean SM, Moffett JK, Gardiner E. Barriers to treatment adherence in physiotherapy outpatient clinics: A systematic review. Man Ther 2010;15(3):220\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eMoher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev 2015;4(1):1.\u003c/li\u003e\n \u003cli\u003eModesti PA, Reboldi G, Cappuccio FP, Agyemang C, Remuzzi G, Rapi S, et al. Panethnic Differences in Blood Pressure in Europe: A Systematic Review and Meta-Analysis. PLoS One 2016;11(1):e0147601.\u003c/li\u003e\n \u003cli\u003eFeder GS. Women Exposed to Intimate Partner Violence. Arch Intern Med 2006;166(1):22.\u003c/li\u003e\n \u003cli\u003eLong HA, French DP, Brooks JM. Optimising the value of the critical appraisal skills programme (CASP) tool for quality appraisal in qualitative evidence synthesis. Research Methods in Medicine \u0026amp; Health Sciences 2020;1(1):31\u0026ndash;42.\u003c/li\u003e\n \u003cli\u003ePopay J, Roberts H, Sowden A, Petticrew M, Arai L, Rodgers M, et al. Guidance on the Conduct of Narrative Synthesis in Systematic Reviews A Product from the ESRC Methods Programme Peninsula Medical School, Universities of Exeter and Plymouth. 2006.\u003c/li\u003e\n \u003cli\u003eGmmash AS, Effgen SK, Skubik-Peplaski C, Lane JD. Parental Adherence to Home Activities in Early Intervention for Young Children with Delayed Motor Development. Phys Ther 2021;101(4).\u003c/li\u003e\n \u003cli\u003eTabachnick BG, Fidell LS, Ullman JB. Using multivariate statistics. pearson Boston, MA; 2013.\u003c/li\u003e\n \u003cli\u003eBaşaran A, Karadavut KI, \u0026Uuml;neri Ş\u0026Ouml;, Balbaloǧlu \u0026Ouml;, Atasoy N. Serebral palsili \u0026ccedil;ocuklarin bakicilarinin ev egzersiz programina uyumlari. Turkiye Fiziksel Tip ve Rehabilitasyon Dergisi 2014;60(2):85\u0026ndash;91.\u003c/li\u003e\n \u003cli\u003eMedina-Mirapeix F, Lillo-Navarro C, Montilla-Herrador J, Gacto-S\u0026aacute;nchez M, Franco-Sierra MA, Escolar-Reina P. Predictors of parents\u0026rsquo; adherence to home exercise programs for children with developmental disabilities, regarding both exercise frequency and duration: A survey design. Eur J Phys Rehabil Med 2017;53(4):545\u0026ndash;55.\u003c/li\u003e\n \u003cli\u003eBollen JC, Dean SG, Siegert RJ, Howe TE, Goodwin VA. A systematic review of measures of self-reported adherence to unsupervised home-based rehabilitation exercise programmes, and their psychometric properties. BMJ Open 2014;4(6):e005044\u0026ndash;e005044.\u003c/li\u003e\n \u003cli\u003eLillo-Navarro C, Montilla-Herrador J, Escolar-Reina P, Oliveira-Sousa S, Garc\u0026iacute;a-Vidal J, Medina-Mirapeix F. Factors Associated with Parents\u0026rsquo; Adherence to Different Types of Exercises in Home Programs for Children with Disabilities. J Clin Med 2019;8(4):456.\u003c/li\u003e\n \u003cli\u003eSel SA, Kerem G\u0026uuml;nel M, Şengelen M, Hayran M. An examination of the Factors Affecting Compliance of Parents 0f Children with Cerebral Palsy to Home Program: A Scale Development Study. Turkish Journal of Physiotherapy and Rehabilitation 2020;\u003c/li\u003e\n \u003cli\u003eGalil A, Carmel S, Lubetzky H, Vered S, Heiman N. Compliance with home rehabilitation therapy by parents of children with disabilities in Jews and Bedouin in Israel. Dev Med Child Neurol [Internet] 2001;43(04):261. Available from: http://doi.wiley.com/10.1017/S0012162201000494\u003c/li\u003e\n \u003cli\u003eLouka-Lazouri I, Hristara-Papadopoulou A, Stavropoulou M, Emmanouil T, Anna C, Ilias K. Investigation of parents\u0026rsquo; compliance in physical therapy at home with toddlers diagnosed with cerebral palsy. International Research Journal of Public and Environmental Health 2020;7(3):52\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eTahayneh M, Humayra S, Fall AA, Rosland H, Amro A, Mohammed A, et al. 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Parents of children with physical disabilities perceive that characteristics of home exercise programs and physiotherapists\u0026rsquo; teaching styles influence adherence: A qualitative study. J Physiother2015;61(2):81\u0026ndash;6.\u003c/li\u003e\n \u003cli\u003eTipping CJ, Scholes RL, Cox NS. A qualitative study of physiotherapy education for parents of toddlers with cystic fibrosis. Journal of Cystic Fibrosis 2010;9(3):205\u0026ndash;11.\u003c/li\u003e\n \u003cli\u003eMcConnell D, Parakkal M, Savage A, Rempel G. Parent-mediated intervention: adherence and adverse effects. Disabil Rehabil 2015;37(10):864\u0026ndash;72.\u003c/li\u003e\n \u003cli\u003eNovak I, Berry J. Home Program Intervention Effectiveness Evidence. Phys Occup Ther Pediatr 2014;34(4):384\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eRiquelme I, Cifre I, Montoya P. Are physiotherapists reliable proxies for the recognition of pain in individuals with cerebral palsy? A cross sectional study. 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Applied psychology 2008;57(4):660\u0026ndash;80.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Home-based exercise programs, cerebral palsy, self-efficacy, depression, anxiety, social support, and gross motor function.","lastPublishedDoi":"10.21203/rs.3.rs-3079847/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3079847/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInvolving parents of children with cerebral palsy (C-CP) in home exercise programmes (HEP) is globally practised and closely linked to improved treatment outcomes for physical performance and function. Nevertheless, non-adherence to HEP is increasing at an alarming rate, and little is known about the factors of adherence to HEP (AHEP) especially in parents of C-CP.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis systematic review was aimed to identify the factors enhancing AHEP among parents of C-CP to reinforce the efficacy of rehabilitation practices proposed by health professionals, researchers, and educators.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe searched PubMed, Scopus, CINHAL, PsycINFO, and Embase\u003cstrong\u003e \u003c/strong\u003efor articles published up to March 2023, that investigated the factors of AHEP among parents of C-CP. We conducted a narrative synthesis using the search results and pertinent material from other sources.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall non-adherence rates to HEP were moderate to high (34%-79.2%). There was strong evidence that factors enhancing AHEP are in three categories: child-related (low age and gross motor function (GMF), caregiver-related (high self-efficacy and knowledge, high social support, low depression, anxiety and stress symptoms, and low perception of barriers), and the physiotherapist-related. For the last category, parents’ perception of a supportive and collaborative relationship with the therapists is one of the conditions mostly favour AHEP.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur findings highlight that factors influencing AHEP are multifactorial. Some of them are conditions that are difficult to change such as FGM or the economic and social conditions of the family. Instead, the relationship between therapist and parent is a dimension that can be strengthened. These results suggest the importance of substantial training and psychosocial support for the therapists to make them more aware of and competent in the need to build a supportive relationship with parents.\u003c/p\u003e","manuscriptTitle":"The psychosocial determinants of adherence to home-based rehabilitation strategies in parents of children with cerebral palsy: A systematic review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-06-26 13:59:57","doi":"10.21203/rs.3.rs-3079847/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2013ecab-7c5a-4846-a2f2-6c490254a985","owner":[],"postedDate":"June 26th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-06-21T14:56:11+00:00","versionOfRecord":{"articleIdentity":"rs-3079847","link":"https://doi.org/10.1371/journal.pone.0305432","journal":{"identity":"plos-one","isVorOnly":true,"title":"PLOS ONE"},"publishedOn":"2024-06-12 14:56:11","publishedOnDateReadable":"June 12th, 2024"},"versionCreatedAt":"2023-06-26 13:59:57","video":"","vorDoi":"10.1371/journal.pone.0305432","vorDoiUrl":"https://doi.org/10.1371/journal.pone.0305432","workflowStages":[]},"version":"v1","identity":"rs-3079847","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3079847","identity":"rs-3079847","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}