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Objectives: Development of a specification for a theory-based intervention to facilitate long-term patient adherence to PR for COPD, and development of a specification for a future definitive Randomised Controlled Trial (RCT) of this intervention. Methods: Five independent yet interrelated studies comprising Stage-One of an integrated two-stage Health Technology Assessment Programme using the organising structure of the UK Medical Research Council Framework for Development and Evaluation of RCTs for Complex Interventions to Improve Health: 1 (Secondary Research): Bibliometric analysis and development of a literature search model for studies of patient adherence in electronic databases; 2 (Secondary Research): A methodological analysis of treatment fidelity in the 23 RCTs included in the Cochrane Review of PR for COPD; 3 (Secondary Research): A systematic review of 4 RCTs of interventions to facilitate adherence to PR for COPD; 4 (Primary Research): A cohort study utilising the Theory of Planned Behaviour to explore, measure and ultimately predict differences in walking exercise adherence between one PR cohort that received 12-months of ongoing ‘maintenance’ PR within a multi-centre surgical RCT and another standard-care PR cohort that did not receive ‘maintenance’ PR; and 5 (Primary Research): A randomised experiment of ‘medication and appointment non-adherent’, ‘socially isolated’ and ‘current smoker’ patient stereotypes on 389 health professionals’ and student health professionals’ estimates of patient adherence to PR for COPD. Conclusion: The Programme objectives were not achieved due to the lack of knowledge and understanding regarding the two fundamental concepts of adherence definition and measurement. Two key underpinning recommendations: i) a methodological review of adherence definition and measurement and ii) a systematic review of the relationship between adherence and treatment outcome are specified.

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“Threshold equalising noise” (TEN) was designed to produce approximately equal masked thresholds for all signal frequencies for people without DRs. When the signal falls inside a DR and is therefore detected via neurones with characteristic frequencies different from the signal frequency, the masked threshold is unusually high. the TEN test was validated by comparison with psychophysical tuning curves and was found to be an appropriate clinical tool for the identification of DR. Hearing-impaired subjects who do not perceive pure tones with a clear pitch were often assumed to have DRs. A systematic study based on subjective ratings of tone clarity showed that tones falling more than ~ 1.5 octaves inside a DR were indeed always rated as somewhat unclear, but a noise-like percept was not necessarily associated with a DR. No correlation was found between noisiness ratings and absolute thresholds across frequencies within ears, but average ratings increased with the severity of the hearing loss. An extensive study of perceived pitch was conducted by obtaining pitch matches across ears of unilaterally hearing-impaired subjects, or within ears using octave matches. The results indicate that tones falling within a DR are perceived with an unclear pitch that is different from “normal”, particularly for tones falling well inside low- or high-frequency DRs. The results indicate that the pitch of low-frequency tones is not conveyed solely by a temporal code, although <i>some </i>temporal information is still available. Possibly, a correspondence between place and temporal information is necessary for a “normal” pitch to be perceived. The pitch of high-frequency tones falling in a DR is probably solely determined by place information. Normally, a sustained tone remains audible when presented at a level well above threshold, except at the upper frequency limit of hearing. In an extensive study using subjects with and without DRs, no consistent association was found between the degree of tone decay and the presence of a DR.