Educational programmes in COPD management interventions: a systematic review

Educational needs of people with COPD or asthma entering pulmonary rehabilitation and their significant others: A cross-sectional study

Objectives: This study aimed to identify educational needs of people with COPD or asthma referred for pulmonary rehabilitation and their significant others. Methods: In this cross-sectional study, information needs were assessed by the Lung Information Needs Questionnaire. Learning styles were assessed with a multiple-choice question (visual, aural, read/write and kinaesthetic - multiple choices were possible). Psychological profiles were assessed by an instrument distinguishing four profiles: fighter, analyst, optimist or sensitive. Results: 121 patients (57% female; age: 65 ± 10 years; 81% COPD) and 67 significant others (55% female; age: 61 ± 12 years) were included. Patients and their significant others had a variety of information needs. Patients and their significant others mostly preferred the aural (39% and 49%, respectively) and read/write learning styles (31% and 36%, respectively) as unimodal learners. 49% of patients and 51% of significant others preferred more than one learning style. Most prevalent psychological profiles were optimist in patients (36%) and fighter in significant others (59%). Discussion: The identified variety in educational needs among people with COPD or asthma and their significant others underlines the importance of addressing this diversity of individual needs in education. Learners should have the opportunity to choose among a variety of topics and have access to multiple learning styles. Furthermore, educational interventions should consider to incorporate different communication strategies.

The effects of a symptom management program on symptom experience and physical function in Thai adults with chronic obstructive pulmonary disease: A single-blind randomized controlled trial study

Background

Adults with Chronic Obstructive Pulmonary Disease (COPD) experience a range of unpleasant symptoms, including fatigue, dyspnea, sleep disturbances, anxiety, and depression, that are interrelated and impact one another. Developing a program to handle simultaneous symptoms poses challenges but offers advantages for adults with COPD in efficiently managing symptoms.

Objective

This study aimed to determine the effects of a symptom management program on symptom experience and physical function in Thai adults with COPD.

Methods

A randomized controlled trial (RCT) with a Repeated Measures design was performed. One hundred and two participants were allocated randomly to either the control group (n = 51) or the experimental group (n = 51). The experimental group received eight weeks of the symptom management program and usual care, while the control care group received only usual care. Data were collected from January 2023 to August 2023 at baseline, 4th weeks, and 8th weeks using the demographic data, the modified Medical Research Council (mMRC), the Pittsburgh Sleep Quality Index (PSQI), the Multidimensional Assessment of Fatigue (MAF), the Hospital Anxiety and Depression Assessment Scale (HADS), the COPD Assessment Test (CAT), and 6-Minute Walk Distance (6-MWD). The hypotheses were analyzed using Repeated Measures Multivariate Analysis of Variance (MANOVA).

Results

The symptom management program significantly impacted the experimental group's symptom experience and physical function at Weeks 4 and 8 (F = 5.257, p <0.001). There were significantly improved mean scores for the mMRC, MAF, 6MWD, and CAT (p <0.001, p <0.05). No statistically significant differences were observed in the PSQI, HADS-Anxiety, and HADS-Depression over time.

Conclusion

Implementing a symptom management program can help patients with COPD efficiently manage their symptoms. In clinical settings, nurses should integrate this program into routine nursing care to enhance the quality of life for patients suffering from COPD. The program can help patients preserve physical functionality while reducing dependence on family and society.

Trial Registry Number

Thai Clinical Trials Registry (TCTR20230111006).

Effectiveness of a home-based pulmonary rehabilitation maintenance programme: the Rehab2Life study protocol

Pulmonary rehabilitation (PR) is the bedrock of non-pharmacological treatment for people with COPD. Nonetheless, it is well described in the literature that unless the patient changes his behaviour, the benefits of PR programmes will decline in six to twelve months after finishing the programme. Therefore, maintenance programmes can address the problem of PR programmes' effect loss over time.Community care units can provide multidisciplinary care in the current Portuguese primary health care context. These units have an interdisciplinary team that aims to develop competencies in COPD patients to self-manage the disease.This study aims to test the effectiveness of a 12-month home-based PR programme (Rehab2Life) compared to usual care through a single-blind randomised controlled trial with two parallel groups. The Rehab2Life programme includes two distinct phases. The first is an 8-week PR programme delivered to both groups, and the second is a PR maintenance programme delivered to the intervention group after the initial eight weeks. The control group receive the usual care and regular appointments. The primary outcome is functional capacity, and secondary outcomes are dyspnea, Health-Related Quality of Life (HRQoL), number of exacerbations, symptoms burden, anxiety and depression symptoms, and physical activity.We expect to observe that the home-based PR programme brings clinically relevant benefits to the participants at the end of the first eight weeks and that, at 12 months after the maintenance phase of the programme, benefits are less dissipated than in the control group. We expect to identify the characteristics of the patients who benefit the most from home-based programmes.The trial was registered on 7 April 2022 at ClinicalTrials.gov (NCT05315505).

Factors Associated with Patient Education in Patients with Chronic Obstructive Pulmonary Disease (COPD) - A Primary Health Care Register-Based Study

Purpose

Patient education in chronic obstructive pulmonary disease (COPD) is recommended in treatment strategy documents, since it can improve the ability to cope with the disease. Our aim was to identify the extent of and factors associated with patient education in patients with COPD in a primary health care setting.

Patients and Methods

In this nationwide study, we identified 29,692 COPD patients with a registration in the Swedish National Airway Register (SNAR) in 2019. Data on patient education and other clinical variables of interest were collected from SNAR. The database was linked to additional national registers to obtain data about pharmacological treatment, exacerbations and educational level.

Results

Patient education had been received by 44% of COPD patients, 72% of whom had received education on pharmacological treatment including inhalation technique. A higher proportion of patients who had received education were offered smoking cessation support, had performed spirometry and answered the COPD Assessment Test (CAT), compared with patients without patient education. In the adjusted analysis, GOLD grade 2 (OR 1.29, 95% CI 1.18-1.42), grade 3 (OR 1.41, 95% CI 1.27-1.57) and grade 4 (OR 1.79, 95% CI 1.48-2.15), as well as GOLD group E (OR 1.17, 95% CI 1.06-1.29), ex-smoking (OR 1.70, 95% CI 1.56-1.84) and current smoking (OR 1.45, 95% CI 1.33-1.58) were positively associated with having received patient education, while cardiovascular disease (OR 0.92, 95% CI 0.87-0.98) and diabetes (OR 0.93, 95% CI 0.87-1.00) were negatively associated with receipt of patient education.

Conclusion

Fewer than half of the patients had received patient education, and the education had mostly been given to those with more severe COPD, ex- and current smokers and patients with fewer comorbidities. Our study highlights the need to enhance patient education at an earlier stage of the disease.

Impact of telephone follow-up on COPD outcomes in pulmonary rehabilitation patients: A randomized clinical trial

Background

The educational component is a comprehensive part of Pulmonary Rehabilitation (PR), and telephone follow-up (TFU) is an alternative to reinforce face-to-face education. The objective was to determine the effect of telephone follow-up on educational needs, dyspnea, quality of life and functional capacity in Chronic Obstructive Pulmonary Disease (COPD) patients undergoing PR.

Methods

Double-blind randomized controlled clinical trial in patients with COPD in a PR program in Cali-Colombia, allocation by randomization tables. All patients received 24 sessions of PR, which included face-to-face education sessions. In addition, the experimental group received telephone calls twice a week to reinforce the face-to-face educational content. The Lung Information Needs Questionnaire (LINQ) was used to measure disease knowledge, the Saint George's Respiratory Questionnaire to measure quality of life, the modified Medical Research Council (mMRC) scale to measure dyspnea, and the 6-minute walking test (6MWT) to measure functional capacity.

Results

Thirty-four patients were randomized and 31 were analyzed. PR group with conventional education (PRTE) n=15 and PR group with education plus telephone follow-up (PRTETFU) n=16. Significant improvement from baseline to endpoint in both groups: LINQ (PRTE 4±1.1, p=0.003, PRTETFU 5.8±10.6, p=0.000), mMRC (PRTE 1.6±0.3, p=0.000, PRTETFU 0.6±0.3, p=0.036) and functional capacity (PM6M: PRTE 45.9m±16.1, p=0.013, PRTETFU 62.8m±21.4, p=0.010). Analysis showed differences between groups for changes in LINQ knowledge domain after intervention, with greater improvement for PRTETFU (p=0.018).

Discussion

The TFU is an alternative to reinforce the education. This study demonstrated greater positive effects for the autonomous management of the pathology.

Conclusion

Adding educational reinforcement through phone calls to patients with COPD during PR leads to improved knowledge and skills for managing the disease.

Knowledge of Vaccination Against Influenza and Pneumococcus in Patients with Chronic Obstructive Pulmonary Disease in an Integrated Care Program

Purpose

To compare the level of knowledge in vaccination against influenza and pneumococcus of patients with chronic obstructive pulmonary disease (COPD) who are managed in an Integrated Care Program (ICP) with those who receive usual care (UC).

Methods

A telephone survey of patients diagnosed with COPD registered in public care networks or private institutions was done. A descriptive and comparative analysis of the characteristics of the ICP and UC groups was carried out. The relationship between belonging to an ICP and the level of knowledge about vaccination was evaluated using Propensity Score Matching (PSM) and multivariate logistic and ordinal regression models.

Results

Of 674 study participants, 27.2% were from the ICP group. ICP patients were older, more frequently men, from a higher socioeconomic stratum and a higher educational level (p<0.05). 75.5% of the patients in the ICP group had a high level of vaccination knowledge compared to 42.7% in the UC group (p<0.001). In the multivariate analysis, adjusting for sociodemographic variables, years of COPD diagnosis, and comorbidities, belonging to the ICP was associated with a higher probability of answering questions about vaccination correctly and having a high level of knowledge (OR 3.397, IC 95% 2.058-5.608, p<0.001).

Conclusion

Patients with COPD managed in an ICP have a higher level of knowledge in vaccination against influenza and pneumococcus, compared to patients in usual care.

[Smoking cessation treatment for smokers with COPD: The importance of therapeutic education]

Smoking is a major risk factor for chronic obstructive pulmonary disease (COPD). The diagnosis of tobacco addiction and management of tobacco dependence are part and parcel of COPD treatment, especially in respiratory rehabilitation. Management encompasses psychological support, validated treatments and therapeutic education. The objective of this review is to briefly recall the guiding principles of therapeutic patient education (TPE) as it applies to smokers wishing to quit and, more specifically, to present the tools conducive to shared educational assessment and treatment according to the Prochaska's stages of change model. We are also proposing an action plan and a questionnaire through which TPE sessions can be assessed. Finally, culturally adapted interventions and new communication technologies are taken into consideration insofar as they constructively contribute to TPE.

Healthcare providers perception of therapeutic patient education efficacy according to patient and healthcare provider characteristics

OBJECTIVES

Therapeutic patient education improves numerous health and psychological outcomes in patients with chronic diseases. However, little is known about what makes a therapeutic patient education intervention more effective than another one. This study aims to identify in healthcare professionals the perceived determinants of therapeutic patient education efficacy at the individual level.

METHODS

Semi-structured individual interviews have been conducted with healthcare professionals (HCP, n=28, including 20 nurses) involved in therapeutic patient education programs (n=14) covering various chronic conditions (kidney and cardiovascular diseases, chronic pain, diabetes, etc.). A thematic content analysis following an inductive approach was used (Nvivo.11 software).

RESULTS

Five themes were retrieved for patient characteristics: understanding and education, personality, readiness and motivation, social environment, and misinformation and beliefs. Four themes were retrieved for healthcare professionals' characteristics: medical knowledge, appropriate attitude and relational skills, pedagogical skills, and training.

DISCUSSION

Patient personality is rarely discussed in the literature. Patients who are introverted, lack curiosity, or are not compliant might benefit from specific therapeutic patient education practices or formats. All these potential determinants regarding patients and healthcare professionals should be routinely assessed in future studies about therapeutic patient education efficacy to understand precisely what makes an intervention successful.

Barriers and facilitators related to self-management of shoulder pain: a systematic review and qualitative synthesis

OBJECTIVE

The objective of this review was to identify barriers and facilitators related to self-management from the perspectives of people with shoulder pain and clinicians involved in their care.

DATA SOURCES

CINAHL, MEDLINE, PsycINFO, SPORTDiscus, Embase, ProQuest Health, Web of Science, and Scopus were searched from inception to March 2022.

REVIEW METHODS

A meta-aggregative approach to the synthesis of qualitative evidence was used. Two independent reviewers identified eligible articles, extracted the data, and conducted a critical appraisal. Two reviewers independently identified and developed categories, with validation by two further researchers. Categories were discussed among the wider research team and a comprehensive set of synthesized findings was derived.

RESULTS

Twenty studies were included. From the perspective of patients, three synthesized findings were identified that influenced self-management: (1) support for self-management, including subthemes related to patient-centred support, knowledge, time, access to equipment, and patient digital literacy; (2) personal factors, including patient beliefs, patient expectations, patient motivation, pain, and therapeutic response; and (3) external factors, including influence of the clinician and therapeutic approach. From the perspective of clinicians, two synthesized findings were identified that influenced self-management: (1) support for self-management, including education, patient-centred support, patient empowerment, time, and clinician digital literacy; and (2) preferred management approach, including clinician beliefs, expectations, motivation, therapeutic approach, and therapeutic response.

CONCLUSION

The key barriers and facilitators were patient-centred support, patient beliefs, clinician beliefs, pain, and therapeutic response. Most of the included studies focused on exercise-based rehabilitation, and therefore might not fully represent barriers and facilitators to broader self-management.

Contemporary Issues and Practicalities in Completing Advance Care Planning for Patients With Severe COPD Living Alone: A Qualitative Study

Health care professionals working with older people living alone with chronic obstructive pulmonary disease (COPD) to complete advance care planning (ACP) often encounter the double burden of social isolation and acute exacerbations in this planning. The study explored clinicians' perceptions regarding factors influencing the completion of ACP for older people with COPD living alone. Individual interviews were conducted with 18 health care professionals using the video meeting platform in 2020. A semi-structured interview guide included: (a) behavior and lifestyle related to decision-making, (b) desired place to die, and (c) facilitators and barriers to autonomy in patients with severe COPD who live alone. Five main themes were identified: information sharing among team members, patient readiness, desired place of death, economic constraints, and care at the time of and after death. Partly due to the heterogeneity and complexity of clinical courses and treatment responses of COPD, a wide range of social issues of a person's life were related to practicality in the completion of ACP for older people with COPD living alone. Social work knowledge and skills such as in-depth interviewing, outreach finance and welfare support, and holistic perspective play an essential role in completing ACP for COPD patients living alone.

Using Telemedicine to Provide Education for the Symptomatic Patient with Chronic Respiratory Disease

Technology-enabled learning, using computers, smartphones, and tablets, to educate patients on their respiratory disease and management has grown over the last decade. This shift has been accelerated by the global COVID-19 pandemic and the need to socially distance for public health. Thirteen recently published papers examined experience, knowledge, skills and attitude acquisition, behaviour change, and impact on health outcomes of patient education using technology (websites and mobile device applications) for people with chronic respiratory disease. Technology-enabled patient education that includes relevant information, with activities that encourage the patient to interact with the digital platform, appears to lead to better patient experience and may increase learning and behaviour change with improved quality of life. Developing online relationships with healthcare providers, lower digital capabilities, and poor access to a computer/smartphone/tablet, appear to be barriers that need to be overcome for equity in access. Maintaining the principles of quality educational design, ensuring interactive experiences for patient involvement in the educational activities, patient co-design, healthcare professionals connecting with experts in the field of technology-enabled learning for development of education models, and ongoing research lead to the best patient outcomes in technology-enabled education for respiratory disease.

Tailored patient therapeutic educational interventions: A patient-centred communication model

Background

Tailoring therapeutic education consists of adapting the intervention to patients' needs with the expectation that this individualization will improve the results of the intervention. Communication is the basis for any individualization process. To our knowledge, there is no guide or structured advice to help healthcare providers (HCPs) tailor patient education interventions.

Objectives

We used a data‐driven qualitative analysis to (1) investigate the reasons why HCPs tailor their educational interventions and (2) identify how this tailoring is effectively conducted. The perspective aimed to better understand how to individualize therapeutic patient education and to disentangle the different elements to set up studies to investigate the mechanisms and effects of individualization.

Design

Individual semistructured interviews with 28 HCPs involved in patient education were conducted. The present study complied with the COREQ criteria.

Results

Why individualization is necessary: participants outlined that the person must be thought of as unique and that therapeutic education should be adapted to the patient's personality and cognitive abilities. The first step in the individualization process was formalized by an initial patient assessment. Several informal practices were identified: if needed, giving an individual time or involving a specific professional; eliciting individual objectives; reinforcing the relationship by avoiding asymmetrical posture; focusing on patients' concerns; leading sessions in pairs; and making the patient the actor of decisions.

Conclusion

From our thematic data analysis, a model for tailoring patient education interventions based on the Haes and Bensing medical communication framework is proposed. The present work paves the way for evaluation, then generation of recommendations and finally implementation of training for individualization in educational interventions.

Short Informative

Tailoring in therapeutic education consists of an adaptation to patients' needs. Communication is the basis for any individualization process. There is no model of patient‐centred communication in educational interventions. From semistructured interviews with HCPs, we propose a patient‐centred communication model for tailoring patient education intervention.

The Effect of a web-based physical activity intervention on COPD knowledge: A secondary cohort study

BACKGROUND

Novel strategies to complement current methods of education delivery by healthcare providers in clinic encounters or in pulmonary rehabilitation are needed to promote COPD self-management.

METHODS

We developed a COPD web-based platform that delivers education as part of a physical activity intervention. We examined COPD knowledge in persons with COPD who used a web-mediated, pedometer-based physical activity intervention. Knowledge was assessed with the Bristol COPD Knowledge Questionnaire (BCKQ) at baseline, 3, 6, 9, and 12 months. Scores range from 0 to 100, with higher scores indicating greater knowledge. Repeated measures ANOVA (PROC MIXED, SAS 9.4) examined trends across the 12 months and identified changes from baseline at 3, 6, 9, and 12 months.

RESULTS

We enrolled 72 participants with COPD, 93% males with mean ± sd age of 69 ± 7 years and FEV1% predicted of 60 ± 23%. There was a significant increase from baseline to 9 months (p = 0.012), although this increase did not persist at 12 months. Among the 13 topics, participants scored the highest at baseline on smoking knowledge (65.3 ± 17.4) and the lowest on inhaled steroids (9.7 ± 15.4). Across the 12 months, there were significant increases in knowledge about inhaled bronchodilators (p = 0.011) and inhaled steroids (p = 0.035). At 12 months, there were significant improvements in knowledge about exercise (p = 0.004), vaccination (p = 0.027), inhaled bronchodilators (p = 0.002), and inhaled steroids (p = 0.002).

CONCLUSION

An internet-mediated intervention may provide another option for COPD education delivery and support for disease self-management.

The information needs of people with COPD-The holistic approach with special reference to gender and time since diagnosis

AIMS

The aim of this study was to determine what kinds of unmet information needs people with COPD have and whether there are differences in information needs between genders or based on the time since COPD diagnosis.

DESIGN

A descriptive cross-sectional study.

METHODS

Data on people with COPD (N = 169) were collected from a two-part questionnaire distributed via website. On the first part, information needs concerning the medical aspects of self-management were measured by the Lung Information Needs Questionnaire (LINQ). On the second part, which was developed specifically for this study, a more holistic view of self-management counselling was sought. Statistical methods were used to analyse the data.

RESULTS

The respondents had wide-ranging information needs in many areas of COPD self-management. The most often reported areas of unmet information needs included exacerbations, diet, fatigue, stress and anxiety, palliative care and sexual life. The information needs varied by gender and time since COPD diagnosis.

Community-based intervention for prevention and management of chronic obstructive pulmonary disease in Nepal (COBIN-P trial): study protocol for a cluster-randomized controlled trial

Background

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of death worldwide and the commonest of non-communicable diseases (NCDs) in Nepal. Risk factors like indoor and outdoor air pollution, a high prevalence of smoking, and the lack of awareness of COPD make it a serious public health concern. However, no attempt has been made in Nepal to estimate its burden and address the disease at the community level.

Method

This study aims to evaluate the effect of a community-based health educational intervention administered by Female Community Health Volunteers (FCHVs) on the prevention and management of COPD. An open-label, two-group, community-based, cluster-randomized controlled trial will be implemented in the semi-urban area of Pokhara Metropolitan city (former Lekhnath Municipality) located in the Kaski district of Nepal. The estimated sample size of the intervention will be 1143. The unit of randomization is the ward (administrative unit) of the study area. The follow-up survey will be conducted immediately after 12 months of FCHVs-led interventions. The difference in the rate of decline of forced expiratory volume in 1 s (FEV₁) and FEV₁/FVC (forced vital capacity) ratio are the primary outcomes and the change in the proportion of modifiable risk factors of COPD, health-related quality of life scores, and change in knowledge of COPD will be secondary outcomes.

Discussion

This study will estimate the burden of COPD, the magnitude of risk factors and generate evidence to mobilize community health workers for COPD prevention and management at the community level in Nepal.

Trial registration

ClinicalTrials.gov NCT03797768. Registered on January 9, 2019.

Impact of an Animation Education Program on Promoting Compliance With Active Respiratory Rehabilitation in Postsurgical Lung Cancer Patients: A Randomized Clinical Trial

BACKGROUND

Non-small cell lung cancer is the most common type of lung cancer. Lung resection is proven to be the most effective curative treatment for early-stage non-small cell lung cancer (stages I-IIIA). Studies show evidence-based pulmonary rehabilitation is critical for improving exercise capacity and pulmonary function, reducing burden of cancer-related symptoms, and facilitating quality of life following a lung resection.

OBJECTIVE

To explore the effectiveness of an animation education program to promote respiratory rehabilitation outcomes for postsurgical lung cancer patients.

INTERVENTIONS/METHODS

Eighty lung cancer patients who had undergone lung resection were equally randomized to 2 groups with 40 participants in each group. The intervention group received animation education. The control group received traditional face-to-face education. The training-related knowledge and exercise compliance were evaluated at baseline, 3 days after education, and the day of discharge, along with related pulmonary functional indicators.

RESULTS

Eighty of 99 eligible participants were enrolled (80.8%). Mean scores of training-related knowledge and exercise compliance in the intervention group were higher than those of the control group. Occurrences of postoperative pulmonary complications and the indwelling time of thoracic drainage tube were lower, and 6-minute walk distance was longer compared with the control group. No statistical differences in other pulmonary functional indicators were found.

CONCLUSIONS

Educational animation is effective for promoting training-related knowledge and exercise compliance with active respiratory rehabilitation in postsurgical lung cancer patients.

IMPLICATIONS FOR PRACTICE

Oncology nurses can implement animation as an innovative educational method for improving cancer patients' uptake and compliance on health education.

Evaluation of an Enhanced Pulmonary Rehabilitation Program: A Randomised Controlled Trial

RATIONALE

Pulmonary rehabilitation (PR) is the most effective strategy to improve health outcomes in people with COPD, although it has had limited success in promoting sustained physical activity. PR with a strong focus on disease self-management may better facilitate long-term behavior change.

OBJECTIVE

To compare a newly developed enhanced pulmonary rehabilitation program (EPR) to a traditional PR program on outcome achievement.

METHODS

In this randomized parallel-group controlled trial, PR classes were block randomized to EPR or traditional PR, which were delivered over 16 sessions each. The EPR incorporated new and updated "Living Well with COPD" education modules which had a stronger focus on chronic disease self-management. Fidelity of the intervention for content and delivery was assessed. Physical activity, self-efficacy, exercise tolerance, and health-related quality of life (HRQoL) were collected before, after, and 6-months following PR. Healthcare visits were collected 2 years before PR and 1 year after. Mortality was recorded 1 year after PR.

RESULTS

Of the 207 COPD patients enrolled, 108 received the EPR and 99 traditional PR. Physical activity (steps) and self-efficacy improved from pre- to post-PR in both programs, with no differences between groups. These effects were not sustained at 6 months. Exercise tolerance and HRQoL improved from pre- to post-PR with no between group differences, which were maintained at 6 months. Visits to primary care providers and respiratory specialists decreased in the EPR program relative to traditional PR. EPR was delivered as intended and there was no meaningful cross-contamination between the two programs.

CONCLUSIONS

Enhancing PR to have a greater emphasis on chronic disease self-management did not result in a superior improvement of physical activity and health outcomes compared to traditional PR except for reduced resource utilization from primary and specialist physician visits in the EPR program. Clinical trial registered with ClinicalTrials.gov (NCT02917915).

Development and Validity Assessment of a Chronic Obstructive Pulmonary Disease Knowledge Questionnaire in Low- and Middle-Income Countries

Rationale: The majority of the morbidity and mortality related to chronic obstructive pulmonary disease (COPD) occurs in low- and middle-income countries (LMICs). Despite the increasing burden of COPD, disease-specific knowledge among healthcare workers and patients in LMICs remains limited. COPD knowledge questionnaires (COPD-KQ) are valid and reliable tools to assess COPD knowledge and can be employed in settings with limited health literacy. Objectives: To develop and assess the validity and reliability of a COPD-KQ among individuals with COPD in three LMIC settings. Methods: Twelve questions were generated by an expert team of 16 researchers, physicians, and public health professionals to create an LMIC-specific COPD-KQ. The content was based on previous instruments, clinical guidelines, focus-group discussions, and questionnaire piloting. Participants with COPD completed the questionnaire across three diverse LMIC settings before and 3 months after delivery of a standardized COPD-specific education package by a local community health worker trained to deliver the education to an appropriate standard. We used paired t tests to assess improvement in knowledge after intervention. Results: Questionnaire development initially yielded 52 items. On the basis of community feedback and expertise, items were eliminated and added, yielding a final 12-item questionnaire, with a maximum total score of 12. A total of 196 participants with COPD were included in this study in Nepal (n = 86), Peru (n = 35), and Uganda (n = 75). The mean ± standard deviation baseline score was 8.0 ± 2.5, and 3 months after education, the mean score was 10.2 ± 1.7. The community health worker-led COPD educational intervention improved COPD knowledge among community members by 2.2 points (95% confidence interval, 1.8-2.6 points; t = 10.9; P < 0.001). Internal consistency using Cronbach's α was 0.75. Conclusions: The LMIC COPD-KQ demonstrates face and content validity and acceptable internal consistency through development phases, suggesting a reliable and valid COPD education instrument that can be used to assess educational interventions across LMIC settings. Clinical trial registered with www.clinicaltrials.gov (NCT03365713).

Educational topics and their rationale for inclusion within pulmonary rehabilitation - a systematic review

OBJECTIVE

To identify the scope of educational topics within pulmonary rehabilitation (PR) for people with chronic respiratory diseases and determine their rationale for inclusion.

METHODS

Four electronic databases were searched, with data extracted and assessed for quality by two reviewers using the Downs and Black tool or the Critical Appraisal Skills Programme checklist.

RESULTS

Twenty-one studies of variable quality were included. In chronic obstructive pulmonary disease (COPD), common education topics included disease pathophysiology, medications, psychological support, strategies for breathlessness, role of exercise and recognition of acute exacerbations, while less frequent topics included end-of-life planning, disease impact on sexual relationships and comorbidities. In interstitial lung disease (ILD), topics focused upon disease pathophysiology, approaches to limit disease progression, symptom management and end-of-life care. Evidence of a rationale for including education topics in PR were often lacking, but focused on recommended guidelines and information to improve self-management.

CONCLUSION

A core range of educational topics based broadly upon clinical presentation and management strategies appear to be incorporated into PR for people with COPD. Topics for people with ILD appear to be selected according to patient need.

PRACTICE IMPLICATIONS

The topics identified in this review may help clinicians seeking to develop educational resources for PR.

Self-Management Training in Chronic Obstructive Lung Disease Improves the Quality of Life

OBJECTIVES

Management of chronic obstructive pulmonary disease (COPD) includes interventions such as improving skills in coping with the disease. We aimed to examine the effect of self-management training on the quality of life and functional parameters in patients with moderate to severe COPD.

MATERIALS AND METHODS

Sixty-one consecutive patients with COPD were recruited in the study prospectively. The patients were randomized into two groups: self-management training (n=31) and standard care (n=30). Each patient was evaluated by spirometry, COPD assessment test (CAT), St George's respiratory questionnaire (SGRQ), hospital anxiety and depression scale (HADS), modified British Medical Research Council (mMRC) dyspnea scale, and short form-36 (SF-36). A team of physiotherapists, psychologists, pulmonary disease specialists, and dietitians provided self-management training and biweekly counseling via phone. At the end of three months, both the groups were re-evaluated using the same assessment parameters.

RESULTS

We found no significant difference between the baseline demographic characteristics of the self-management training and standard care groups. We observed a reduction in CAT (p<0.001), SGRQ impact (p=0.013), activity subscales (p<0.001) and the total scores (p=0.020), and HADS anxiety (p=0.012) and depression (p=0.014) scores in the self-management training group after the education session. A significant increase in SF-36 physical function score was also observed (p=0.008). No significant improvement in the functional parameters was observed in either group; however, the change in FEV1 was more pronounced in the self-management training group than in the control group (p=0.017). The hospital readmissions and 1-year survival rates were similar for both the groups after receiving education (p>0.05).

CONCLUSION

Our results suggest that the self-management training of the patients with COPD improves the quality of life and reduces the symptoms of depression and anxiety. Therefore, at the least, self-management training should be done as the first step of pulmonary rehabilitation in patients with COPD who cannot access pulmonary rehabilitation facilities.

Psychosocial issues need more attention in COPD self-management education

Objective: To find out how regularly the contents of patient education regarded as essential for COPD patients' self-management are provided by healthcare professionals in specialised healthcare (SHC) and primary healthcare (PHC) in Finland.Design: A cross-sectional study based on an e-questionnaire with 42 items on the content of self-management education of COPD patients.Setting: The study sample included all public SHC units with pulmonary outpatient clinics (n = 29) and nine out of 160 health centres in Finland.Subjects: 83 doctors and 162 nurses.Main outcome measures: The respondents' answers on how regularly they included the contents regarded as essential for COPD patients' self-management in their education of COPD patients.Results: COPD patients were educated regularly on medical issues regarding COPD treatment, such as smoking cessation, exercise and pharmacological treatment. However, issues vital for coping with the disease, such as psychological well-being, stress management or fatigue, were often ignored. Patient education in SHC seemed to be more systematic than education in PHC. The education provided by the asthma/COPD nurses (n = 70) was more systematic than the education provided by the other nurses (n = 84).Conclusion: Healthcare professionals' continuous education should cover not only the medical but also the psychosocial aspects of coping with COPD. The role of doctors and nurses should be considered to ensure that there is no gap in COPD patients' education. Training asthma/COPD nurses and promoting specialised nurse-led asthma/COPD clinics in primary care could be beneficial while improving practices of patient education that enhance patients' ability to cope with the disease.KEY POINTSIssues vital for coping with chronic obstructive pulmonary disease (COPD), such as psychological well-being, stress and fatigue, are irregularly included in self-management education both in primary and specialised healthcare.Patient education provided by asthma/COPD nurses is more regular than patient education provided by other nurses.The distribution of work between doctors and nurses should be considered to ensure that there is no gap in COPD patients' education.

The Self-Care in Chronic Obstructive Pulmonary Disease Inventory: Development and Psychometric Evaluation

This study developed two instruments, the Self-Care in Chronic Obstructive Pulmonary Disease (COPD) Inventory (SC-COPDI) and the COPD-Self-Care Self-Efficacy Scale (SCES), and tested their psychometric properties on a convenience sample of 498 patients from Northern, Central, and Southern Italy. First, the domains and the items of the SC-SCOPDI were generated based on the middle-range theory of self-care of chronic illness, comprising the dimensions of self-care maintenance, self-care monitoring, and self-care management, and the SCES-COPD was developed accordingly. Second, we assessed the content validity of each scale. Third, we conducted a multicenter cross-sectional study to test their structural validity, convergent and discriminative validity, internal consistency, and test–retest reliability. The theoretical dimensions of the two instruments were confirmed through confirmatory factor analysis. Convergent validity was demonstrated by the correlation among the three self-care scales and the Self-Efficacy Scale, and discriminative validity by higher self-care scale scores in individuals with greater COPD severity and poorer health status. The global reliability index ranged from .78 to .92 for all scales. The intraclass correlation coefficients were higher than .70. Further studies are needed to confirm the psychometric properties of the two instruments in different COPD populations and countries to extend their use in clinical practice.

Improving access to community-based pulmonary rehabilitation: 3R protocol for real-world settings with cost-benefit analysis

Background

Pulmonary rehabilitation (PR) has demonstrated patients’ physiological and psychosocial improvements, symptoms reduction and health-economic benefits whilst enhances the ability of the whole family to adjust to illness. However, PR remains highly inaccessible due to lack of awareness of its benefits, poor referral and availability mostly in hospitals. Novel models of PR delivery are needed to enhance its implementation while maintaining cost-efficiency. We aim to implement an innovative community-based PR programme and assess its cost-benefit.

Methods

A 12-week community-based PR will be implemented in primary healthcare centres where programmes are not available. Healthcare professionals will be trained. 73 patients with CRD and their caregivers (dyads patient-caregivers) will compose the experimental group. The control group will include dyads age- and disease-matched willing to collaborate in data collection but not in PR. Patients/family-centred outcomes will be dyspnoea (modified Medical Research Council Questionnaire), fatigue (Checklist of individual strength and Functional assessment of chronic illness therapy – fatigue), cough and sputum (Leicester cough questionnaire and Cough and sputum assessment questionnaire), impact of the disease (COPD Assessment Test), emotional state (The Hospital Anxiety and Depression Scale), number of exacerbations, healthcare utilisation, health-related quality of life and family adaptability/cohesion (Family Adaptation and Cohesion Scale). Other clinical outcomes will be peripheral (biceps and quadriceps-hand held dynamometer, 1 or 10 repetition-maximum) and respiratory (maximal inspiratory and expiratory pressures) muscle strength, muscle thickness and cross sectional area (biceps brachialis, rectus femoris and diaphragm-ultrasound imaging), exercise capacity (six-minute walk test and one-minute sit to stand test), balance (brief-balance evaluation systems test) and physical activity (accelerometer). Data will be collected at baseline, at 12 weeks, at 3- and 6-months post-PR.

Changes in the outcome measures will be compared between groups, after multivariate adjustment for possible confounders, and effect sizes will be calculated. A cost-benefit analysis will be conducted.

Discussion

This study will enhance patients access to PR, by training healthcare professionals in the local primary healthcare centres to conduct such programmes and actively involving caregivers. The cost-benefit analysis of this intervention will provide an evidence-based insight into the economic benefit of community-based PR in chronic respiratory diseases.

Trial registration

The trial was registered in the ClinicalTrials.gov U.S. National Library of Medicine, on 10th January, 2019 (registration number: NCT03799666).

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7045-1) contains supplementary material, which is available to authorized users.

Rehabilitation in lung diseases: 'Education' component of pulmonary rehabilitation

Pulmonary rehabilitation (PR) is a complex intervention with described core components of individualized exercise training and inter-disciplinary education in international guidelines. Compared to the overwhelming evidence of benefit for exercise training, the education component has received little attention. Educating patients about their symptoms and disease management appears intuitive to improve their health, but how and when is less clear. PR has provided an opportunity for educational activities and traditionally this has been delivered in the form of didactic lectures. The field is evolving and challenges are apparent raising important questions. What is the purpose and outcomes of the education component? Do specific diseases require specific education or PR programmes? How to provide interdisciplinary education? Is the timing optimal within the disease trajectory (most patients are referred to PR with moderate to severe disease)? Can technology help? Our review explores the recent evidence for the 'education' component of PR synthesizing the global guidelines. We discuss the challenges for patients as learners, healthcare professionals as educators and propose future directions for this core component of PR.

Patient education during hospital admission due to exacerbation of chronic obstructive pulmonary disease: Effects on quality of life-Controlled and randomized experimental study

The objective of this study was to assess the effectiveness of an education program and telephone call follow-up at improving the health related quality of life (HRQL) of patients with chronic obstructive pulmonary disease (COPD).

METHOD

Experimental, controlled, randomized, single blind study, masked data analysis. Duration of 2 years and 3 months. Patients hospitalised for exacerbation. The effectiveness was evaluated by calculating the absolute and relative change (%) of the St. George questionnaire scores (total and by dimensions) before and after the intervention program. Calculation of the effect of the group variable on the absolute and relative changes of the variables, Multiple Analysis of Variance (MANOVA).

RESULTS

Completed study of 116 patients. Greater effects on their HRQL reported at admission (48.3 ± SD 20.0 years). Patients in the intervention group improved significantly in their total SGRQ scores (-6.83) in absolute and relative terms and more significantly in their activity dimension (-16.05).

CONCLUSIONS

The education program was effective at improving global HRQL, especially the activity dimension, in exacerbated COPD patients.

PRACTICE IMPLICATIONS

This research contributes to clarifying the benefits and contents of education programs for patients with COPD; hospital admission is the suitable moment to contact these patients.

COPD patient education and support - Achieving patient-centredness

BACKGROUND

The art of medicine is undergoing a dramatic shift in focus, evolving to focus on patient involvement as partners in care, transforming the traditional, prescriptive, reactive practice of healthcare into a proactive discipline. The personal and societal burden of chronic diseases is burgeoning and unsustainable in current systems, novel approaches are required to address this.

DISCUSSION

Although considerable progress has been made in the development of diagnostics, therapeutics and care guidelines for patients with chronic obstructive pulmonary disease (COPD), questions remain surrounding the implementation of best practice education and support. Current educational programmes, personal limitations and preferences and patient-clinician communication in modification of coping styles and behaviour are discussed. A novel holistic model, the Kaleidoscope Model of Care is proposed to address the barriers to optimal self-care behaviours.

CONCLUSION AND PRACTICE IMPLICATIONS

Holistic approaches are essential for optimal self-management and improved outcomes. Guidance on personalised goals for patients to help meeting their therapy priorities is needed to aid healthcare professionals (HCPs) and funders to minimise healthcare burden and costs. The novel KALMOD approach may optimise patient empowerment, exploring whole-life factors that impact COPD care and improve interactions between patients and HCPs for optimised outcomes.

Evaluation of multidisciplinary pulmonary rehabilitation education delivered by either DVD or spoken talk

INTRODUCTION

Pulmonary rehabilitation (PR) is a multidisciplinary program of care for patients with chronic respiratory disease. The educational component is an integral component and represents a large proportion of a program. However, it can be difficult to secure regular multidisciplinary input to PR programs.

OBJECTIVES

This service evaluation assessed whether DVD presentations are acceptable to patients and effective as an education medium.

METHOD

Two PR groups were compared; one group received education by DVD and the other by spoken talk. Both groups evaluated the content and delivery of each session and their knowledge was measured using the Bristol COPD Knowledge Questionnaire (BCKQ).

RESULTS

One hundred and twenty-three patients with Chronic Obstructive Pulmonary Disease (COPD) took part; 58 evaluated the DVD, 75 the talk sessions. There were no differences between the two groups at baseline with respect to age, gender distribution, or FEV₁ . Both groups were satisfied with the content (99.46% DVD, 100% talk group) and delivery (100% both DVD and talk groups) of their education sessions. At baseline, there were no between group differences in the mean BCKQ. After PR, significant changes in BCKQ scores were seen within the groups (6.52 points (1.48-11.37) DVD group and 8.96 points (6.50-11.19) talk group), again with no differences between the groups.

CONCLUSION

A DVD-based education package is both acceptable to PR patients and effective at improving patients' knowledge of COPD. Using filmed educational talks with PR would have a number of benefits to both the patients and the service and may be a way of increasing the capacity of PR services.

Incorporating telemedicine into the integrated care of the COPD patient a summary of an interdisciplinary workshop held in Stresa, Italy, 7-8 September 2017

This report is a summary of a workshop focusing on using telemedicine to facilitate the integrated care of chronic obstructive pulmonary disease (COPD). Twenty-five invited participants from 8 countries met for one and one-half days in Stresa, Italy on 7-8 September 2017, to discuss this topic. Participants included physiotherapists, nurses, a nurse practitioner, and physicians. While evidence-based data are always at the center of sound inference and recommendations, at this point in time the science behind telemedicine in COPD remains under-developed; therefore, this document reflects expert opinion and consensus. While telemedicine has great potential to expand and improve the care of our COPD patients, its application is still in its infancy. While studies have demonstrated its effectiveness in some patient-centered outcomes, the results are by no means consistently positive. Whereas this tool may potentially reduce health care costs by moving some medical interventions from centralized locations in to patient's home, its cost-effectiveness has had mixed results and telemonitoring has yet to prove its worth in the COPD population. These discordant results should not be unexpected in view of patient complexity and the heterogeneity of telemedicine. This is reflected in the very limited support offered by the National Health Services to a wider application of telemedicine in the integrated care of COPD patients. However, this situation should challenge us to develop the necessary science to clarify the role of telemedicine in the medical management of our patients, providing a better and definitive scientific basis to this approach.

Self-Management Support Needs of Patients with Chronic Diseases in a South African Township: A Qualitative Study

Despite the need for chronic disease self-management strategies in developing countries, few studies have aimed to contextually adapt programs; yet culture has a direct impact on the way people view themselves and their environment. This study aimed to explore the knowledge, attitudes, and self-management needs and practices of patients with chronic diseases. Four patient focus groups (n = 32), 2 patient interviews, group observations, and key informant interviews (n = 12) were conducted. Five themes emerged: health-system and service-provision challenges, healthcare provider attitudes and behavior, adherence challenges related to medication and lifestyle changes, patients' personal and clinic experiences and self-management tool preferences. The findings provide a window of opportunity for the development of contextually adapted self-management programs for community health nursing in developing countries.

The Unmet Needs of People with Chronic Obstructive Pulmonary Disease: A Systematic Review of Qualitative Findings

The complexity of chronic obstructive pulmonary disease (COPD) can negatively impact the lives of people with the condition and compromise their capacity to take care of their needs. Unmet needs can then lead to significant morbidity, unpleasant emotional experiences and a poor quality of life; thus this systematic review aimed to identify, evaluate and synthesise the qualitative literature on the unmet needs of people with COPD. A qualitative meta-synthesis was performed according to the Joanna Briggs Institute method. A systematic search of five databases was conducted, searching for articles published from January 1995 to May 2017. Eight papers were identified. Two researchers extracted the data and independently assessed their quality. The total sample of people with COPD included was 108. Nine categories were derived from 49 findings, and aggregated into three synthesised findings: (1) people with COPD have unmet needs regarding information about the disease; (2) people with COPD have unmet physical, emotional and social needs, due to the disease symptoms and treatments; and (3) people with COPD have unmet care needs. This review showed qualitative evidence regarding the dimensions in which people with COPD express their unmet needs. The needs that are mainly unsatisfied include physical, psychosocial, informational and practical aspects, as well as the need for healthcare professional care. A global approach, which includes the areas identified by our findings, could lead to an improvement in the care of people with COPD and could improve the self-care management of those individuals who do not correctly identify their needs.

Patient Education Provided by Physiotherapists for Patients with Chronic Obstructive Pulmonary Disease: Results of a Scoping Review

Purpose: Physiotherapists have been acknowledged as playing a vital role in the care of people living with chronic obstructive pulmonary disease (COPD), and this care includes providing patient education (PE). Yet very little is known about the issues critical to providing this PE. The purpose of this scoping review was to identify and map out the current knowledge about the content, processes, and overall effectiveness of the PE provided by physiotherapists for people living with COPD. Method: Using the guidelines developed by Arksey and O'Malley in 2005 and by Levac in 2010, key databases were searched. A total of 447 articles were identified and screened for the following inclusion criteria: adults living with COPD, published in English or French between 1995 and 2015, and describing the PE provided by physiotherapists. Fourteen studies matched these criteria. Results: In the majority of studies, both physiotherapists and nurses provided PE to patients. Common PE topics included energy conservation, exacerbations, and breathlessness. None of the studies included measures for evaluating the effectiveness of the PE. Conclusions: Even though physiotherapists routinely provide PE to people living with COPD, this PE varies substantially. The heterogeneity of the studies and lack of measures of effectiveness prevented them from providing any evidence-based recommendations for physiotherapists.

Knowledge gaps in patients with COPD and their proxies

Background

Although proxies of patients with chronic obstructive pulmonary disease (COPD) need health-related knowledge to support patients in managing their disease, their current level of knowledge remains unknown. We aimed to compare health-related knowledge (generic and COPD-related knowledge) between patients with COPD and their resident proxies.

Methods

In this cross-sectional study, we included stable patients with moderate to very severe COPD and their resident proxies (n = 194 couples). Thirty-four statements about generic health and COPD-related topics were assessed in patients and proxies separately. Statements could be answered by ‘true’, ‘false’, or ‘do not know’. This study is approved by the Medical Research Ethics Committees United (MEC-U), the Netherlands (NL42721.060.12/M12–1280).

Results

Patients answered on average 17% of the statements incorrect, and 19% with ‘do not know’. The same figure (19%) for the incorrect and unknown statements was shown by proxies. Patients who attended pulmonary rehabilitation previously answered more statements correct (about three) compared to patients who did not attend pulmonary rehabilitation. More correct answers were reported by: younger patients, patients with a higher level of education, patients who previously participated in pulmonary rehabilitation, patients with better cognitive functioning, and patients with a COPD diagnosis longer ago.

Conclusions

Proxies of patients with COPD as well as patients themselves answer about two third of 34 knowledge statements about COPD correct. So, both patients and proxies seem to have an incomplete knowledge about COPD and general health. Therefore, education about general health and COPD should be offered to all subgroups of patients with COPD and their proxies.

Trial registration

This study is registered in the Dutch Trial Register (NTR3941). Registered 19 April 2013.

Nursing clinical practice changes to improve self-management in chronic obstructive pulmonary disease

AIM

To propose nursing clinical practice changes to improve the development of patient self-management.

BACKGROUND

Chronic obstructive pulmonary disease is one of the main causes of chronic morbidity, loss of quality of life and high mortality rates.

INTRODUCTION

Control of the disease's progression, the preservation of autonomy in self-care and maintenance of quality of life are extremely challenging for patients to execute in their daily living. However, there is still little evidence to support nursing clinical practice changes to improve the development of self-management.

METHODS

A participatory action research study was performed in a medicine inpatient department and the outpatient unit of a Portuguese hospital. The sample comprised 52 nurses and 99 patients. For data collection, we used interviews, participant observation and content analysis.

RESULTS

The main elements of nursing clinical practice that were identified as a focus for improvement measures were the healthcare model, the organization of healthcare and the documentation of a support decision-making process. The specific guidelines, the provision of material to support decision-making and the optimization of information sharing between professionals positively influenced the change process. This change improved the development of self-management skills related to the awareness of the need for 'change', hope, involvement, knowledge and abilities.

DISCUSSION

The implemented changes have improved health-related behaviours and clinical outcomes.

CONCLUSION

To support self-management development skills, an effective nursing clinical practice change is needed. This study has demonstrated the relevance of a portfolio of techniques and tools to help patients adopt healthy behaviours.

IMPLICATIONS FOR NURSING AND/OR HEALTH POLICY

The involvement and participation of nurses and patients in the conceptualization, implementation and evaluation of policy change are fundamental issues to improve the quality of nursing care and clinical outcomes.

Characterization of secondary care for COPD in Sweden

Introduction: Only a selected proportion of chronic obstructive pulmonary disease (COPD) patients are managed in secondary care. The aim of this study was to characterize disease severity, treatment and structure of secondary care for COPD in Sweden. Methods: Information was collected from 29 of 33 existing secondary care units of respiratory medicine in Sweden, using both individual data from 373 consecutively enrolled COPD patients with Global initiative on Obstructive Lung Disease (GOLD) stage III-IV and a structural questionnaire about available resources at the units. Patient data included exacerbations, health status assessed by COPD Assessment Test (CAT), lung function, comorbid conditions, pharmacological treatment and vaccinations. Structural data included available smoking cessation support, multidisciplinary rehabilitation, physical training, patient education and routine follow-up after exacerbations at the respective unit. All patients were reclassified according to the GOLD 2014 group A-D classification. Multiple linear regression investigated associations of available resources with number of exacerbations and CAT score. Results: According to GOLD 2014, 87% of the population were GOLD D and 13% were GOLD C. Triple inhaled therapy were prescribed in 88% of the patients. Over 75% of the units had resources for smoking cessation, multidisciplinary rehabilitation, physical training and patient education. Routine follow-up after exacerbations was available in 35% of the units. Being managed at units with access to structured patient education was associated with statistically significantly fewer exacerbations (adjusted regression coefficient (95% confidence interval) -0.79 (-1.39 to -0.19), p = 0.010). Conclusion: Most stage III-IV COPD patients managed at secondary care respiratory units in Sweden have maximized inhaled therapy and high risk disease even when reclassified according to GOLD 2014. Most units have access to smoking cessation, rehabilitation and patient education. Patients managed at units with structured patient education have a lower exacerbation risk.

Why Don't Our Patients with Chronic Obstructive Pulmonary Disease Listen to Us? The Enigma of Nonadherence

Nonadherence--not taking pharmacologic or nonpharmacologic treatments according to agreed recommendations from a health care provider--is common in patients with chronic obstructive pulmonary disease. Nonadherence in taking maintenance medications, smoking cessation, maintaining regular physical activity and exercise, starting and staying in pulmonary rehabilitation and continuing on with the postrehabilitation exercise/activity prescription, and successfully following self-management directions results in adverse outcomes across multiple areas. These include a faster decline in airway function, higher symptom burden, impaired health status, and increased health care use and mortality risk. Although nonadherence can also occur in health care providers (not following established treatment guidelines), this perspective focuses on patient nonadherence. Factors such as social/economic, health system, therapy-related, patient-related, and condition-related factors all impact this problem. To improve patient adherence, we need to consider these factors in the context of people with chronic obstructive pulmonary disease and implement strategies directly targeting underlying issues. Strategies may include customizing and simplifying learning and intervention regimes, identifying barriers to adherence and addressing them, ensuring patient support structures are in place, and improving self-efficacy. Future directions should focus on research and development in educational design; use of technology to assist education; psychological intervention strategies to support learning, motivation, self-efficacy and behavior change; and ways to improve healthcare providers' engagement with patients.

Global and regional estimates of COPD prevalence: Systematic review and meta-analysis

Background

The burden of chronic obstructive pulmonary disease (COPD) across many world regions is high. We aim to estimate COPD prevalence and number of disease cases for the years 1990 and 2010 across world regions based on the best available evidence in publicly accessible scientific databases.

Methods

We conducted a systematic search of Medline, EMBASE and Global Health for original, population–based studies providing spirometry–based prevalence rates of COPD across the world from January 1990 to December 2014. Random effects meta–analysis was conducted on extracted crude prevalence rates of COPD, with overall summaries of the meta–estimates (and confidence intervals) reported separately for World Health Organization (WHO) regions, the World Bank's income categories and settings (urban and rural). We developed a meta–regression epidemiological model that we used to estimate the prevalence of COPD in people aged 30 years or more.

Findings

Our search returned 37 472 publications. A total of 123 studies based on a spirometry–defined prevalence were retained for the review. From the meta–regression epidemiological model, we estimated about 227.3 million COPD cases in the year 1990 among people aged 30 years or more, corresponding to a global prevalence of 10.7% (95% confidence interval (CI) 7.3%–14.0%) in this age group. The number of COPD cases increased to 384 million in 2010, with a global prevalence of 11.7% (8.4%–15.0%). This increase of 68.9% was mainly driven by global demographic changes. Across WHO regions, the highest prevalence was estimated in the Americas (13.3% in 1990 and 15.2% in 2010), and the lowest in South East Asia (7.9% in 1990 and 9.7% in 2010). The percentage increase in COPD cases between 1990 and 2010 was the highest in the Eastern Mediterranean region (118.7%), followed by the African region (102.1%), while the European region recorded the lowest increase (22.5%). In 1990, we estimated about 120.9 million COPD cases among urban dwellers (prevalence of 13.2%) and 106.3 million cases among rural dwellers (prevalence of 8.8%). In 2010, there were more than 230 million COPD cases among urban dwellers (prevalence of 13.6%) and 153.7 million among rural dwellers (prevalence of 9.7%). The overall prevalence in men aged 30 years or more was 14.3% (95% CI 13.3%–15.3%) compared to 7.6% (95% CI 7.0%–8.2%) in women.

Conclusions

Our findings suggest a high and growing prevalence of COPD, both globally and regionally. There is a paucity of studies in Africa, South East Asia and the Eastern Mediterranean region. There is a need for governments, policy makers and international organizations to consider strengthening collaborations to address COPD globally.

Supported self-management for patients with moderate to severe chronic obstructive pulmonary disease (COPD): an evidence synthesis and economic analysis

BACKGROUND

Self-management (SM) support for patients with chronic obstructive pulmonary disease (COPD) is variable in its coverage, content, method and timing of delivery. There is insufficient evidence for which SM interventions are the most effective and cost-effective.

OBJECTIVES

To undertake (1) a systematic review of the evidence for the effectiveness of SM interventions commencing within 6 weeks of hospital discharge for an exacerbation for COPD (review 1); (2) a systematic review of the qualitative evidence about patient satisfaction, acceptance and barriers to SM interventions (review 2); (3) a systematic review of the cost-effectiveness of SM support interventions within 6 weeks of hospital discharge for an exacerbation of COPD (review 3); (4) a cost-effectiveness analysis and economic model of post-exacerbation SM support compared with usual care (UC) (economic model); and (5) a wider systematic review of the evidence of the effectiveness of SM support, including interventions (such as pulmonary rehabilitation) in which there are significant components of SM, to identify which components are the most important in reducing exacerbations, hospital admissions/readmissions and improving quality of life (review 4).

METHODS

The following electronic databases were searched from inception to May 2012: MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and Science Citation Index [Institute of Scientific Information (ISI)]. Subject-specific databases were also searched: PEDro physiotherapy evidence database, PsycINFO and the Cochrane Airways Group Register of Trials. Ongoing studies were sourced through the metaRegister of Current Controlled Trials, International Standard Randomised Controlled Trial Number database, World Health Organization International Clinical Trials Registry Platform Portal and ClinicalTrials.gov. Specialist abstract and conference proceedings were sourced through ISI's Conference Proceedings Citation Index and British Library's Electronic Table of Contents (Zetoc). Hand-searching through European Respiratory Society, the American Thoracic Society and British Thoracic Society conference proceedings from 2010 to 2012 was also undertaken, and selected websites were also examined. Title, abstracts and full texts of potentially relevant studies were scanned by two independent reviewers. Primary studies were included if ≈90% of the population had COPD, the majority were of at least moderate severity and reported on any intervention that included a SM component or package. Accepted study designs and outcomes differed between the reviews. Risk of bias for randomised controlled trials (RCTs) was assessed using the Cochrane tool. Random-effects meta-analysis was used to combine studies where appropriate. A Markov model, taking a 30-year time horizon, compared a SM intervention immediately following a hospital admission for an acute exacerbation with UC. Incremental costs and quality-adjusted life-years were calculated, with sensitivity analyses.

RESULTS

From 13,355 abstracts, 10 RCTs were included for review 1, one study each for reviews 2 and 3, and 174 RCTs for review 4. Available studies were heterogeneous and many were of poor quality. Meta-analysis identified no evidence of benefit of post-discharge SM support on admissions [hazard ratio (HR) 0.78, 95% confidence interval (CI) 0.52 to 1.17], mortality (HR 1.07, 95% CI 0.74 to 1.54) and most other health outcomes. A modest improvement in health-related quality of life (HRQoL) was identified but this was possibly biased due to high loss to follow-up. The economic model was speculative due to uncertainty in impact on readmissions. Compared with UC, post-discharge SM support (delivered within 6 weeks of discharge) was more costly and resulted in better outcomes (£683 cost difference and 0.0831 QALY gain). Studies assessing the effect of individual components were few but only exercise significantly improved HRQoL (3-month St George's Respiratory Questionnaire 4.87, 95% CI 3.96 to 5.79). Multicomponent interventions produced an improved HRQoL compared with UC (mean difference 6.50, 95% CI 3.62 to 9.39, at 3 months). Results were consistent with a potential reduction in admissions. Interventions with more enhanced care from health-care professionals improved HRQoL and reduced admissions at 1-year follow-up. Interventions that included supervised or unsupervised structured exercise resulted in significant and clinically important improvements in HRQoL up to 6 months.

LIMITATIONS

This review was based on a comprehensive search strategy that should have identified most of the relevant studies. The main limitations result from the heterogeneity of studies available and widespread problems with their design and reporting.

CONCLUSIONS

There was little evidence of benefit of providing SM support to patients shortly after discharge from hospital, although effects observed were consistent with possible improvement in HRQoL and reduction in hospital admissions. It was not easy to tease out the most effective components of SM support packages, although interventions containing exercise seemed the most effective. Future work should include qualitative studies to explore barriers and facilitators to SM post exacerbation and novel approaches to affect behaviour change, tailored to the individual and their circumstances. Any new trials should be properly designed and conducted, with special attention to reducing loss to follow-up. Individual participant data meta-analysis may help to identify the most effective components of SM interventions.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42011001588.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Global and regional estimates of COPD prevalence: Systematic review and meta-analysis

BACKGROUND

The burden of chronic obstructive pulmonary disease (COPD) across many world regions is high. We aim to estimate COPD prevalence and number of disease cases for the years 1990 and 2010 across world regions based on the best available evidence in publicly accessible scientific databases.

METHODS

We conducted a systematic search of Medline, EMBASE and Global Health for original, population-based studies providing spirometry-based prevalence rates of COPD across the world from January 1990 to December 2014. Random effects meta-analysis was conducted on extracted crude prevalence rates of COPD, with overall summaries of the meta-estimates (and confidence intervals) reported separately for World Health Organization (WHO) regions, the World Bank's income categories and settings (urban and rural). We developed a meta-regression epidemiological model that we used to estimate the prevalence of COPD in people aged 30 years or more.

FINDINGS

Our search returned 37 472 publications. A total of 123 studies based on a spirometry-defined prevalence were retained for the review. From the meta-regression epidemiological model, we estimated about 227.3 million COPD cases in the year 1990 among people aged 30 years or more, corresponding to a global prevalence of 10.7% (95% confidence interval (CI) 7.3%-14.0%) in this age group. The number of COPD cases increased to 384 million in 2010, with a global prevalence of 11.7% (8.4%-15.0%). This increase of 68.9% was mainly driven by global demographic changes. Across WHO regions, the highest prevalence was estimated in the Americas (13.3% in 1990 and 15.2% in 2010), and the lowest in South East Asia (7.9% in 1990 and 9.7% in 2010). The percentage increase in COPD cases between 1990 and 2010 was the highest in the Eastern Mediterranean region (118.7%), followed by the African region (102.1%), while the European region recorded the lowest increase (22.5%). In 1990, we estimated about 120.9 million COPD cases among urban dwellers (prevalence of 13.2%) and 106.3 million cases among rural dwellers (prevalence of 8.8%). In 2010, there were more than 230 million COPD cases among urban dwellers (prevalence of 13.6%) and 153.7 million among rural dwellers (prevalence of 9.7%). The overall prevalence in men aged 30 years or more was 14.3% (95% CI 13.3%-15.3%) compared to 7.6% (95% CI 7.0%-8.2%) in women.

CONCLUSIONS

Our findings suggest a high and growing prevalence of COPD, both globally and regionally. There is a paucity of studies in Africa, South East Asia and the Eastern Mediterranean region. There is a need for governments, policy makers and international organizations to consider strengthening collaborations to address COPD globally.

Changing physical activity and sedentary behaviour in people with COPD

People with chronic obstructive pulmonary disease (COPD) engage in low levels of physical activity (PA). Given the evidence for the health benefits associated with participating in 150 min of moderate-to-vigorous intensity PA each week, there is considerable interest in methods to increase PA in people with COPD. Studies to date have focused largely on exercise training and behavioural approaches, and many have demonstrated minimal, if any effect. An intermediate goal that focuses on reducing time spent in sedentary behaviour (SB) and increasing participation in light intensity PA is a more realistic goal in this population and offers a gateway to higher intensity PA. Although strategies that are capable of reducing time spent in SB in COPD are unknown, studies that have shown some increase in PA in this population often provide individualized goal setting, motivational interviewing and frequent contact with health-care professionals to provide advice regarding strategies to overcome barriers. Therefore, these approaches should be considered in interventions to reduce time in SB. There are a range of devices available to monitor time in SB for use in both clinical and research settings. To move this area forward, a theoretically informed and systematic approach to behaviour change is needed. The theoretical model, the 'behaviour change wheel', is described and an example is provided of how it can be applied to a person with COPD.

Differences in change in coping styles between good responders, moderate responders and non-responders to pulmonary rehabilitation

INTRODUCTION

Pulmonary rehabilitation (PR) improves exercise tolerance and health status in patients with chronic obstructive pulmonary disease (COPD). Data on the effects of PR on coping styles are limited. Aim of the present study was to compare changes in coping styles between patients who had a good, moderate and no improvement in either exercise tolerance or health status after PR.

METHODS

Coping styles of 439 COPD patients undergoing PR were assessed by the Utrecht Coping List (UCL) at baseline and after PR. Patients' pulmonary function, six-minute walking distance (6MWD), St. George's Respiratory Questionnaire (SGRQ) and Hospital Anxiety and Depression Scale (HADS-A and HADS-D) were recorded. Good, moderate and non-responders were defined on the basis of minimally clinically important difference (MCID) for SGRQ total score and/or 6MWD.

RESULTS

Overall, 54.0% of the patients fulfilled the criteria for good responders, while 22.1% were moderate responders. Change in passive reaction pattern coping style differed significantly between good responders and non-responders following PR (p < 0.001). Moreover, within the groups, changes in coping styles after PR occurred among the good responders, whereas the majority of moderate responders' and non-responders' coping styles were not significantly influenced by PR.

CONCLUSION

Good responders decreased their passive reaction pattern coping style in contrast to non-responders after PR. In general, PR did not change the coping among moderate and non-responders. Further research is warranted to determine whether including interventions targeting coping styles may modify coping behaviour of COPD patients, as well as improvement in exercise tolerance or health status after PR.

A family-focused intervention for heart failure self-care: conceptual underpinnings of a culturally appropriate intervention

AIM

A discussion of the conceptual elements of an intervention tailored to the needs of Lebanese families.

BACKGROUND

The role of informal caregiving is strongly recommended for individuals with chronic conditions including heart failure. Although this importance is recognized, conceptual and theoretical underpinnings are not well elucidated nor are methods of intervention implementation.

DESIGN

Discussion paper on the conceptual underpinning of the FAMILY model.

METHODS AND DATA SOURCES

This intervention was undertaken using linked methods: (1) Appraisal of theoretical model; (2) review of systematic reviews on educational interventions promoting self-management in chronic conditions in four databases with no year limit; (3) socio-cultural context identification from selected papers; (4) expert consultation using consensus methods; and (5) model development.

RESULTS

Theories on self-care and behavioural change, eighteen systematic reviews on educational interventions and selected papers identifying sociocultural elements along with expert opinion were used to guide the development of The FAMILY Intervention Heart Failure Model. Theory and practice driven concepts identified include: behavioural change, linkage, partnership and self-regulation.

IMPLICATIONS FOR NURSING

Heart failure is a common condition often requiring in-hospital and home-based care. Educational interventions targeting the socio-cultural influences of the patients and their family caregivers through a structured and well-designed program can improve outcomes.

CONCLUSION

As the burden of chronic diseases increases globally, particularly in emerging economies, developing models of intervention that are appropriate to both the individual and the socio-cultural context are necessary.

Attitudes of healthcare professionals providing pulmonary rehabilitation toward partnership in care

OBJECTIVES

This multicenter study sought to explore attitudes of pulmonary rehabilitation (PR) professionals toward self-management and which patients' competencies are considered important.

BACKGROUND

Self-management in patients with chronic obstructive pulmonary disease (COPD) requires a patients' active role. Whether patient-clinician partnership in care is supported by PR professionals remains unknown.

METHODS

Attitudes of 75 PR professionals were assessed using an online version of the Clinician Support - Patient Activation Measure (CS-PAM) 13™.

RESULTS

Mean CS-PAM 13™ activation score was 66.5 (11.9) points - professionals support patient's participation in the care process. However, competencies related to patient as member of a care team and patient as an independent information seeker were only extremely important for 30.7-38.7% and 9.3-17.3% of the professionals, respectively.

CONCLUSION

PR professionals embrace the idea of a patients' active role in the process of COPD self-management. Nonetheless, endorsement of the patient's involvement as an independent information seeker is needed.

Engaging community stakeholders to evaluate the design, usability, and acceptability of a chronic obstructive pulmonary disease social media resource center

Background

Patients with chronic obstructive pulmonary disease (COPD) often report inadequate access to comprehensive patient education resources.

Objective

The purpose of this study was to incorporate community-engagement principles within a mixed-method research design to evaluate the usability and acceptability of a self-tailored social media resource center for medically underserved patients with COPD.

Methods

A multiphase sequential design (qual → QUANT → quant + QUAL) was incorporated into the current study, whereby a small-scale qualitative (qual) study informed the design of a social media website prototype that was tested with patients during a computer-based usability study (QUANT). To identify usability violations and determine whether or not patients found the website prototype acceptable for use, each patient was asked to complete an 18-item website usability and acceptability questionnaire, as well as a retrospective, in-depth, semistructured interview (quant + QUAL).

Results

The majority of medically underserved patients with COPD (n=8, mean 56 years, SD 7) found the social media website prototype to be easy to navigate and relevant to their self-management information needs. Mean responses on the 18-item website usability and acceptability questionnaire were very high on a scale of 1 (strongly disagree) to 5 (strongly agree) (mean 4.72, SD 0.33). However, the majority of patients identified several usability violations related to the prototype’s information design, interactive capabilities, and navigational structure. Specifically, 6 out of 8 (75%) patients struggled to create a log-in account to access the prototype, and 7 out of 8 patients (88%) experienced difficulty posting and replying to comments on an interactive discussion forum.

Conclusions

Patient perceptions of most social media website prototype features (eg, clickable picture-based screenshots of videos, comment tools) were largely positive. Mixed-method stakeholder feedback was used to make design recommendations, categorize usability violations, and prioritize potential solutions for improving the usability of a social media resource center for COPD patient education.