Self-Care Behaviors and Quality of Life Among Patients with Chronic Obstructive Pulmonary Disease

Introduction

Chronic obstructive pulmonary disease (COPD) affects a substantial proportion of the adult population and remains a leading cause of chronic morbidity and healthcare utilization, characterized by progressive airflow limitation, persistent respiratory symptoms, and recurrent acute exacerbations that frequently precipitate emergency department visits and hospitalization (Global Initiative for Chronic Obstructive Lung Disease, 2023). Unlike acute respiratory conditions, effective long-term management of COPD depends substantially on the sustained performance of self-care behaviors by the patient in the home setting, including correct and consistent inhaler technique, adherence to prescribed pharmacotherapy, breathing and energy conservation techniques, activity pacing, and early recognition of symptom changes signaling impending exacerbation.

Health-related quality of life has become a central outcome measure in COPD care, given that the disease’s symptom burden, including dyspnea, fatigue, and activity limitation, exerts a pervasive influence on patients’ physical, emotional, and social functioning that is not fully captured by physiologic measures such as forced expiratory volume in one second (FEV1) alone. Prior research has established that disease severity, as measured by spirometric staging, correlates only modestly with patient-reported quality of life, suggesting that other factors, potentially including the degree to which patients actively engage in self-care behavior, may meaningfully contribute to variation in quality of life independent of underlying physiologic impairment (Jones, 2019; Kessler et al., 2021).

The theoretical framework of self-care in chronic illness, as articulated in the Middle-Range Theory of Self-Care of Chronic Illness, distinguishes between self-care maintenance, behaviors performed routinely to preserve health stability, and self-care management, the recognition of and response to changes in symptoms once they occur (Riegel et al., 2019). Both dimensions are theorized to influence illness trajectory and patient-reported outcomes, yet much of the existing COPD self-care literature has examined isolated behaviors, such as inhaler technique or pulmonary rehabilitation attendance, in relative isolation, rather than evaluating the relative contribution of distinct self-care domains, including symptom recognition and early management specifically, to overall quality of life within the same patient population using a validated, multidimensional self-care instrument.

Given the centrality of quality of life as a COPD outcome and the incomplete characterization of which specific self-care domains most strongly relate to quality of life, this study aimed to examine the relationship between self-care behavior engagement, assessed using a validated multidimensional instrument, and health-related quality of life among adults with COPD, and to identify which specific self-care domains demonstrated the strongest independent association with quality of life after accounting for disease severity and exacerbation history.

Methods

This study employed a descriptive, correlational cross-sectional design conducted across four outpatient pulmonary clinics affiliated with a single regional health system, over a 5-month data collection period. Adults aged 40 years or older with a spirometrically confirmed diagnosis of COPD, defined as a post-bronchodilator FEV1/forced vital capacity ratio below 0.70, who were established patients at a participating clinic, were eligible for inclusion. Patients with a concurrent diagnosis of active malignancy, severe cognitive impairment, or an acute exacerbation requiring hospitalization within the preceding 4 weeks were excluded, to ensure that quality of life reporting reflected patients’ typical stable-state disease experience rather than an acute exacerbation episode. A total of 274 patients completed the study survey during a routine outpatient visit.

Self-care behavior was assessed using the Self-Care of Chronic Obstructive Pulmonary Disease Inventory (SC-COPDI), a validated, disease-specific instrument comprising three subscales: self-care maintenance, addressing routine health-preserving behaviors such as medication adherence and activity engagement; self-care monitoring, addressing the consistency with which patients observe and track their own symptoms; and self-care management, addressing recognition of and response to worsening symptoms. Health-related quality of life was assessed using the St. George’s Respiratory Questionnaire (SGRQ), a validated, COPD-specific instrument yielding a total score as well as subscale scores addressing symptoms, activity limitation, and disease impact, with higher scores indicating poorer quality of life. Disease severity was characterized using spirometric FEV1 percent predicted obtained from the patient’s most recent pulmonary function test on record, and exacerbation history was assessed through both self-report and chart review of exacerbation-related healthcare utilization over the preceding 12 months.

Three primary data domains were collected and analyzed:

1.Self-care behavior scores across the three SC-COPDI subscales (maintenance, monitoring, and management), each scored on a standardized 0-to-100 scale with higher scores reflecting more consistent self-care engagement.

2.Health-related quality of life, measured using the SGRQ total score and its three subscales, along with a single-item global health rating for descriptive comparison.

3.Clinical and demographic covariates, including FEV1 percent predicted, number of exacerbations in the preceding 12 months, comorbidity count, age, and years since COPD diagnosis.

The primary analysis examined the association between SC-COPDI subscale scores and SGRQ total score using multivariate linear regression, adjusting for FEV1 percent predicted, exacerbation frequency, comorbidity count, and age. Bivariate correlations were also examined between individual SC-COPDI subscale scores and each SGRQ subscale to characterize domain-specific relationships. Statistical significance was set at p < .05, and analyses were conducted using SPSS version 29.

Results

The study sample had a mean age of 68.4 years (SD = 9.7), a mean FEV1 percent predicted of 54.2% (SD = 17.8), consistent with a predominantly moderate-to-severe disease severity distribution, and a mean of 1.6 exacerbations (SD = 1.9) in the preceding 12 months. Mean self-care maintenance, monitoring, and management subscale scores were 68.3 (SD = 16.4), 61.7 (SD = 18.9), and 58.2 (SD = 20.6) respectively, indicating that self-care management, the domain addressing recognition of and response to worsening symptoms, was on average the least consistently performed of the three self-care dimensions within this sample.

In the adjusted multivariate linear regression model, higher composite self-care behavior score was significantly associated with lower (better) SGRQ total score, indicating better quality of life, independent of FEV1 percent predicted, exacerbation frequency, comorbidity count, and age (standardized β = −0.38, p < .001). This association remained significant even after accounting for disease severity, indicating that self-care behavior explained a meaningful portion of quality of life variation beyond what physiologic impairment alone would predict.

Examination of individual SC-COPDI subscales revealed that the self-care management subscale, addressing symptom recognition and early response behavior, demonstrated the strongest independent association with SGRQ total score among the three subscales (standardized β = −0.44, p < .001), followed by self-care maintenance (standardized β = −0.29, p < .001), while self-care monitoring showed a weaker, though still statistically significant, independent association (standardized β = −0.17, p = .014). At the subscale-specific level, self-care management scores demonstrated their strongest association with the SGRQ impact subscale, which captures the broader psychosocial and functional consequences of respiratory disease, suggesting that timely recognition and response to symptom changes may be particularly protective against the disease’s broader intrusion into patients’ emotional and social functioning, beyond its direct relationship to physical symptom burden. Notably, self-reported inhaler technique adherence, while prevalent among 81% of the sample, showed a comparatively modest independent association with quality of life once other self-care domains were accounted for in the adjusted model, suggesting that behavioral consistency in symptom recognition and response may carry greater independent relevance to lived quality of life than medication technique adherence in isolation.

Discussion

The findings of this study demonstrate that self-care behavior engagement was independently and meaningfully associated with health-related quality of life among patients with COPD, beyond the contribution of disease severity and exacerbation history alone. This finding reinforces the theoretical premise of the Middle-Range Theory of Self-Care of Chronic Illness, which posits that the behavioral dimensions of chronic disease management, not solely the underlying physiologic disease state, meaningfully shape patient-reported illness experience and outcome (Riegel et al., 2019), and extends this framework with disease-specific, quantitative evidence within a COPD population.

The finding that self-care management, the domain addressing symptom recognition and early response, demonstrated the strongest independent association with quality of life, and that this domain was also the least consistently performed among the three self-care dimensions assessed, carries direct implications for COPD patient education priorities. Much of existing COPD self-management education has historically emphasized inhaler technique and medication adherence as primary teaching targets, given their direct relevance to guideline-based pharmacotherapy delivery. The present findings suggest that comparatively less emphasis may have been placed on cultivating patients’ skill and confidence in recognizing early symptom change and initiating an appropriate self-management response, despite this domain demonstrating the strongest relationship to patients’ overall quality of life and being the domain in which patients in this sample demonstrated the lowest average competency.

The particularly strong association observed between self-care management and the SGRQ impact subscale, which captures broader psychosocial and functional disease burden, suggests a plausible mechanism by which symptom recognition and response skill may influence quality of life beyond direct symptom relief. Patients who feel confident in their ability to recognize and appropriately respond to early symptom change may experience reduced anxiety and greater perceived control over their illness trajectory, factors that have been independently associated with better psychosocial adjustment to chronic respiratory disease in prior qualitative and quantitative research (Kessler et al., 2021; Bourbeau et al., 2018). This interpretation aligns with self-efficacy theory, which suggests that perceived capability to manage a health threat, rather than the objective severity of the threat alone, substantially influences psychological and functional outcomes.

This study has several limitations. The cross-sectional design precludes causal inference, and it remains possible that patients with better quality of life are, for reasons related to lower symptom burden or greater energy availability, more capable of engaging in self-care behavior, rather than self-care behavior driving quality of life exclusively; the relationship observed is likely bidirectional in practice. Self-report measurement of self-care behavior, while employing a validated instrument, may be subject to social desirability bias, potentially inflating reported adherence to self-care behaviors relative to actual practice. The single regional health system setting may limit generalizability to populations with different access to pulmonary specialty care or differing baseline disease education exposure. Future research employing longitudinal designs, and directly evaluating whether targeted interventions to improve self-care management skill specifically produce measurable downstream improvement in quality of life, would strengthen causal understanding of this relationship and directly test the intervention implications suggested by these findings. Despite these limitations, the consistency and independent strength of the observed association support prioritizing symptom recognition and early self-management skill-building, alongside existing inhaler technique and adherence education, within comprehensive COPD patient education and pulmonary rehabilitation programs.

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