The vision of older COPD patients with different knowledge and motivations:a qualitative study to understand the barriers and recommendations to improving self-management

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Methods: We used ethnographic methods(over 1000 hours of observations for 30 participants), and conducted 34 semi-structured interviews with different types of COPD patients. Data were analysed using inductive thematic analysis. Results: According to the IMB model, we divide participants into three categories, namely low-information and low motivation group, high information but low motivation group and low- information but strong motivation group. In the first group, due to the single source of information and decreased memory capacity. Also, patients showed a low perceived threat of disease and negation of self-management value, which led to the lack of self-management knowledge and motivation for this group of patients. In the second group, patients were pessimistic about the cure of the disease because of too much information or too much attention to the details of knowledge, which was also the reason why patients were unwilling to implement the self-management although they had mastered enough knowledge. The third type of patients, with strong motivation, would seek health information resources through various channels. Because of this, they could easily catch incorrect or unscientific information, which would make the situation worse. Conclusion: This qualitative study suggest COPD patients exhibit distinct self-management experiences, barriers, and recommendations due to variations in information processing and motivational characteristics. Future research should tailor precise self-management strategies based on individual patient profiles. Health sciences/Diseases Health sciences/Health care Older COPD patients knowledge motivations qualitative study Figures Figure 1 Figure 2 Figure 3 Introduction Chronic obstructive pulmonary disease (COPD) is a chronic respiratory disease with no cure that can cause a range of symptoms including dyspnea, cough, expectoration and systemic inflammation, especially in the elderly [1]. Self-management has been advocated for mitigating disease progression, curbing medical costs, and enhancing health-related quality of life among COPD patients [2]. Despite the prevalent reports on the benefits of self-management, COPD patients continue to exhibit a suboptimal level of self-management skills. In China, approximately 50% of COPD patients demonstrated low to moderate overall self-management abilities [3]. The factors contributing to this status are many and likely include the knowledge of self-management and the motivation to implement it, as advocated by the Information-Motivation-Behavioral skills (IMB) model:as individuals acquire knowledge regarding health management strategies and their motivation intensifies, they progressively master and refine the behavioral skills required for positive transformation. In essence, the IMB model highlights the pivotal role of these three components in fostering a proactive stance towards health management (Figure 1) [4]. Among COPD patients exhibiting suboptimal self-management behaviors, a subset may possess limited self-management knowledge, some may be devoid of motivation for sustained self-care, while others may experience both these deficiencies. Nevertheless, the self-management experiences and barriers faced by COPD patients lacking either information, motivation, or both, may vary significantly. Drawing upon the core elements of the IMB model, we can categorize these patients into three distinct groups: low-information and low motivation, high information but low motivation, and low- information but strong motivation. Qualitative research may help improve the quality of care that people receive through providing a detailed and nuanced picture of their experiences. However, previous studies have primarily focused on exploring the experiences and barriers of self-management among COPD patients [5,6]. An in-depth analysis of patients with varying factors of self-management barriers (such as three distinct groups above) and the differences in their self-management experiences and barriers has not been conducted. In this study, we aimed to identify opportunities for improving care based on the experiences and perspectives of different types of COPD patients with suboptimal self-management behaviors. The recommendations for different types of COPD patients may vary, and such targeted advice may yield better results. Methods Study Design, Participants, and Settings We conducted ethnographic observations and semi-structured interviews with patients aged 40 years and older who had been diagnosed with stable COPD, and hospitalized in a comprehensive hospital located in southwest China, a region reporting the highest prevalence of COPD (20.2% compared to 15.6% in Northeast China and 13.6% in Northwest China) [7]. We identified participants via a data query that provided the contact information for individuals had been hospitalized for COPD, and called them to make an appointment. Purposive sampling captured a diverse sample in terms of gender and place of residence. The Medical Ethical Committee of the Medical Center Hospital of Qionglai city approved the study (NO 202356).We have informed the participants of the purpose and significance of the study, and obtained the participants' consent and signed the informed consent form. We confirmed that all methods were performed in accordance with the relevant guidelines and regulations, and all procedures were performed in accordance with the Declaration of Helsinki. We used consolidated criteria for reporting qualitative research (COREQ) to guide the design and reporting of this study [8]. Data Collection We conducted semi-structured interviews for 34 participants in the hospital and over 1000 hours of ethnographic observations for additional 30 participants in their home from April 2022 to February 2024. Initially, we assessed participants' knowledge of COPD self-management, which encompassed daily medication adherence, recognition and management of acute exacerbation, oxygen therapy, physical exercise regimens, and respiratory function training. Following this, we administered the Patient Activation Measure 13 (PAM-13) to evaluate their level of patient activation, thereby assessing their motivation. Based on their knowledge and motivation, we categorized the participants into three distinct groups (patient selection and classification procedures:Figure2). Then, we conducted 34 semi-structured interviews with participants, and were conducted in Chinese by three female nurses (XCM, MD; NYW, BS; JL, BS), who have received training in qualitative study and have extensive experience in interviews, through face-to-face communication. The interview guide (Table 1) was developed based on a literature review of COPD self-management [9,10]. The entire interview process adhered strictly to principles of voluntary participation and confidentiality, taking place in a serene and undisturbed environment conducive to candid sharing. The interviews ranged from 15 to 60 minutes, were fully recorded by voice recorder, and promptly transcribed within 24 hours, and transcribed documents were returned to the participants for confirmation. Follow-up interviews were conducted to address any gaps, and data collection ceased once saturation was achieved. Researchers actively prompted participants to articulate their authentic experiences and sentiments. Subsequently, ethnographic observations were conducted in the homes of 30 participants after the semi-structured interviews. Observations focused on daily self-management behaviors and motivations, and consisted of respiratory function exercise, inhalant use, home oxygen therapy, physical activity, and diet. The general focus of work occurring in these homes for about 12 days per site. This enables us to gain a deeper insight into the participants' self-management implementation, encompassing the specifics and accuracy of execution. Furthermore, it facilitates the distinct differentiation between active and passive execution, along with an analysis of the correctness and intensity of these two distinct modes of execution. Fieldwork consisted of over 1000 hours of observations and informal conversations with 30 patients and their family members. Fieldnotes were written up into Word documents. Data analysis We used the software NVivo 11.0 for data analysis and Excel for data management. All interviews were tape recorded and transcribed verbatim. Two authors, each equipped with expertise in social and respiratory medicine, and having undergone rigorous qualitative research training, reviewed and coded the transcripts. We used content analysis for data analysis, including reading the transcribed materials carefully to identify meaningful units, code them and generate themes, coding and analysis was performed according to the principles of thematic analysis. During the process of data analysis, two authors independently completed the task of identifying broad description categories. The two authors discussed their observations in depth, classified the data according to related emerging topics, and then improved the codes together. When it is possible to make other explanations, a third author will be consulted to reach consensus. Finally, a list of categories and subcategories was made [11]. The findings of our topic were fed back to the participants. Results Participants’ characteristics 64 individuals participated in the study. 25 participants were classified as individuals with inadequate information and low motivation, and only 2 participants reported a relatively high educational level. In groups of participants with ample information but insufficient motivation, consisting of 19 individuals, and 7 participants reported a relatively high educational level. However, among participants with limited information but strong motivation (consisting of 20 individuals), approximately 11 members reported having a moderate education level ( Table 2). Themes We developed 6 main themes that reflect experiences with barriers to self-management (Table 3). Each theme includes examples with additional detail about participants’ qualitative experiences. However, significant differences in self-management experiences exist in the three groups. Perspectives of low-information and low motivation group Theme 1: lack of self-management knowledge The limited self-management capabilities of these patients stem primarily from a deficiency in self-management knowledge. This stems from their relatively weak educational backgrounds or rural residences, which collectively hinder their access, acquisition, and comprehension of health-related information. Notably, some patients reported never having received formal self-management education, particularly those who have not been hospitalized for COPD or undergone standardized COPD treatment. Further examination reveals that these patients predominantly adopt a passive learning approach, lacking the motivation to actively seek health knowledge from diverse sources, thereby constraining the expansion of their knowledge base. Compounding this issue, some patients indicate that healthcare providers often deliver relevant management information only during times of disease exacerbation or active treatment, resulting in reduced immediacy of knowledge absorption and long-term retention. Moreover, even when patients initially demonstrate proficiency in skills and knowledge, age and disease-related memory decline impedes their ability to sustainably retain this information over time, ultimately affecting the consistency and effectiveness of their self-management capabilities. Theme 2: weak motivation of self-management The self-management motivation of such COPD patients is notably inadequate, which can be attributed to the combined effects of multiple cognitive and emotional factors. Specifically, some patients fail to fully recognize the potential harm of COPD and the pivotal role of self-management in disease control due to their low frequency of acute exacerbation and mild symptoms. Others tend to overly rely on pharmacotherapy while neglecting the positive effects of self-management. Another group of patients, plagued by recurrent and severe symptoms, experienced intense feelings of frustration and hopelessness, leading to weakened will to survive and subsequent passive attitudes, refusing or struggling to adhere to medical protocols and daily self-management tasks. Furthermore, some patients have adapted to COPD symptoms, establishing a lifestyle that coexists with the disease, lacking the motivation to alter their status quo to meet stricter disease management requirements. This population is often constrained by lower levels of education and their rural residency, resulting in generally limited self-management abilities and a pronounced reliance on external support, particularly the long-term dependence on healthcare providers. In the realm of health management, they exhibited a heavy reliance on the guidance and intervention of professional medical personnel. Moreover, due to a lack of recognition of their active role in disease management, these patients tend to underestimate their self-efficacy, leading to passive self-management behaviors that hinder their proactive engagement in health maintenance and disease management processes. Perspectives of high information but low motivation group Theme 1: unsatisfactory absorption of knowledge This group is primarily concentrated among those with higher cultural literacy who have long resided in urban environments. They have extensively and deeply delved into the knowledge and information in the field of health management through diversified channels. However, due to the abundance of information sources and the vast amount of information, this segment of the population may encounter the problem of information overload when confronted with intricate and complex health information, subsequently leading to feelings of confusion and disorientation. Furthermore, given their tendency towards rigorous and meticulous behavior, some patients may exhibit a heightened focus and pursuit of details in health management practices, potentially even slipping into an excessive obsession with the minutiae of health management, thereby neglecting the effectiveness and sustainability of overall health management. Theme 2: unwillingness to self-management This group possesses relatively abundant knowledge about the specific medical condition, yet they lack the motivation to engage in self-management. Unlike patients with inadequate information and low motivation, this group fully acknowledges the incurability of COPD, hence firmly believing that self-management is futile. On the other hand, some patients are unable to meet the demands of self-management due to their difficulty in altering existing lifestyle habits. Perspectives of low- information but strong motivation group Theme 1: low-efficiency knowledge form This patient population was predominantly concentrated in rural areas and generally possessed a moderate level of education. Despite the fact that some patients did not fully acquire the relevant knowledge system for self-management, they exhibited a profound aspiration for good health, manifested in a strong willingness and motivation to engage in self-management practices. Consequently, they tend to actively seek knowledge and skills related to self-management through diverse channels. However, due to a relative lack of rational evaluation capabilities, the information acquired in this process may be inaccurate or unscientific, potentially posing a threat to the effectiveness and safety of their self-management efforts. Theme 2: excessive activation state This group demonstrated a pronounced level of concern and proactive approach towards their own health status, evidenced by their robust execution of health behaviors. They actively seek and integrated diverse resources to acquire knowledge and skills for self-management and health promotion. Once equipped with these skills, they tend to maintain consistent implementation over time. Nevertheless, it was noteworthy that this group exhibited a relatively weak capacity in evaluating the authenticity of health information, rendering them susceptible to non-expert or misleading external opinions during the information acquisition and execution process. Consequently, they may adopt and followed inaccurate or unscientific health guidelines, posing additional challenges for healthcare professionals in assessing the effectiveness of their self-management efforts. Comparisons of experience among three groups Each displaying unique differences in health information and self-management motivation, as illustrated in Figure 3. Specifically, for patients who lack both information and motivation, the core issue is limited understanding of COPD or inability to effectively comprehend and retain health-related knowledge, which may also significantly contribute to their low motivation. Conversely, patients who have limited access to information but exhibit strong motivation face the primary challenge of easily adopting and implementing inaccurate or unscientific health information, which may potentially exacerbate their symptoms. Their high level of self-management motivation actually increases the likelihood of persisting in erroneous behavioral patterns. As for patients who are well-informed but lack motivation, despite possessing sufficient knowledge of treatment and health management, it is precisely this knowledge base that may lead them to overly focus on minor physical changes and psychologically magnify these changes, potentially resulting in anxiety. This classification highlights the importance of tailored interventions to address the specific challenges faced by each patient type in order to improve COPD care and management. Strategies to optimize self-management Comparison of the results of three types of COPD patients and some promising strategies to optimize self-management of them. Table 4 gives a description of the identified strategies, the problem they aim to overcome. Based on a comprehensive analysis, we identified several key aspects: the necessity of an initial assessment of self-management knowledge and motivation; For those with insufficient information and low motivation, it is highly necessary to provide essential knowledge through channels such as popular science education and free consultations, and implement cognitive rehabilitation and memory compensation strategies for patients with memory decline. For those proficient in knowledge yet lacking motivation, we prioritize bolstering motivation through peer support networks or familial oversight. For patients with scarce information yet robust motivation, ensuring access to precise knowledge or verification pathways is vital. Regular follow-ups and fostering family involvement in monitoring are crucial to prevent the acquisition of erroneous information. Discussion Our study yielded several barriers that influence self-management of different types of COPD patients based on the information-motivation-behavioral skills model. We found that different types of COPD patients have different experiences of self-management disorder, and we identified strategies to optimize competencies of different types of COPD patients. We discern those with inadequate information and low motivation exhibited distinct challenges in navigating barriers to self-care practices, as compared to individuals with abundant information but sufficient motivation. As posited by Hibbard and colleagues, low-activation patients exhibited marked deficits in health literacy, management skills, and valuing self-care, hence termed "passive patients [12]. This underscores the need for tailored interventions that not only enhance informational access but also motivate and empower such individuals to actively engage in their health. Hence, patients with low activation exhibit suboptimal health knowledge, skills, and beliefs, with disparities rooted in distinct experiences. Notably, those with inadequate information and low motivation predominantly reside in lower-educated or rural settings, lacking systematic education, which resulted in limited comprehension of disease management, mirroring prior findings [5]. In addition, another study confirmed that COPD patients were prone to cognitive impairment, and the incidence of cognitive impairment in patients with COPD can be up to 56.5%[13]. COPD patients often experience impairments in attention, memory, and executive functions, pivotal for self-management. This manifests in poor communication with healthcare providers, hindering information reception. Memory deficits further compromise long-term retention of health knowledge, undermining patients' ability to apply acquired information [14]. Therefore, patients with COPD often lack effective knowledge about health management. According to the IMB model, it can be deduced that information can influence motivation [15]. We can understand it as: when patients lack sufficient health knowledge, their beliefs, confidence, and actions in carrying out healthy behaviors will be significantly lacking. Consequently, patients will demonstrate specific behaviors related to a weak motivation for self-management, manifesting as fatalistic views or reluctance to adjust lifestyles. Strengthening self-management knowledge is paramount, achieved via science popularization, medical consultations, and for memory-impaired patients, memory strategies or cognitive training. Our findings indicated that patients with sufficient knowledge but lacking motivation were predominantly those with some cultural awareness or are relatively youthful. Despite familiarity with COPD self-management, their motivation remains low, possibly due to a perceived incurability and belief that self-management efforts are futile. These entrenched beliefs hinder agreement with medical advice. However, peer support has been effective in enhancing compliance with self-management, as they tend to resonate with shared experiences from those in similar circumstances [16]. Therefore, engaging COPD patients who excel in self-management to share their positive experiences could bolster the motivation of informed yet unmotivated patients. Additionally, fostering family involvement in overseeing and supporting the patient's self-management practices is pivotal to enhancing overall outcomes. Consistent with our study, notable disparities emerged in the self-management experiences of COPD patients based on their informational and motivational profiles. Specifically, those with inadequate information and low motivation, as well as those with limited information but strong motivation, confronted comparable challenges in health literacy, notably the scarcity of health information. Prior research echoes this, highlighting unclear inhaler instructions and inadequate communication between healthcare providers and patients as primary barriers to compliance, further underlining the need for targeted interventions to address these gaps [17]. Patients with limited information but strong motivation exhibited elevated levels of activation, resulting in superior overall execution capabilities. Notably, they proactively utilized tools to compensate for memory deficits, sought diverse information sources to address their health knowledge gaps, and seamlessly integrated disease management into their daily routines, fostering habit formation. Another study also demonstrated that higher patient activation levels positively correlate with engagement in health-promoting behaviors [12]. In addition, patients with high motivation were more likely to obtain the information they need from healthcare providers [18]. Despite their heightened motivation, and proficiency in maintaining healthy habits, these patients faced a significant disadvantage:an inability to critically assess the veracity of information, leading them to readily accept others' opinions and potentially perpetuate incorrect health behaviors over time. This predicament posed a formidable challenge for healthcare professionals, who were tasked with delivering scientific, and tailored health education while also monitoring patients' adherence to evidence-based practices. Consequently, it was imperative to empower these patients with the means to discern knowledge accuracy and to encourage familial support in monitoring their behaviors, thereby mitigating the risk of unscientific practices. Limitations There are limitations to this study. First, various regions of China are not homogeneous, and our findings should not be generalized to all patients with COPD. Second, the interviews with a few inactive interviewees were short. They were reticent to share their thoughts about the topic. We employed a convenience sampling method, which may have led to selection bias in the study subjects. Conclusions Drawing upon the IMB model, the suboptimal self-management behaviors observed among COPD patients can be categorized into three distinct types, each with unique experiences of encountering barriers to self-care. We propose the adoption of tailored improvement measures specific to each type of COPD patient. By offering targeted health education or enhancement strategies that are grounded in patients' individual types and their respective self-management challenges, we can foster an environment conducive to the enhancement of patients' self-management capabilities. Declarations or Contributors XMC, NYW, JL conducted the data collection and analysis and produced the initial draft of the manuscript. YXH and LW implemented the intervention and commented on drafts. RZ reviewed and commented on drafts. YNY is the qualitative lead and overall guarantor, conducted analysis and reviewed and edited the work. Data availability statement: Data are available from the corresponding author upon reasonable request. Conflict of Interest Disclosures: No conflict of interest Patient consent for publication: Not applicable Ethics approval This study involves human participants and was approved by the Medical Ethical Committee of the Medical Center Hospital of Qionglai city approved the study (NO 202356). Participants gave informed consent to participate in the study before taking part. We confirmed that all methods were performed in accordance with the relevant guidelines and regulations, and all procedures were performed in accordance with the Declaration of Helsinki. Funding/Support: This study was supported by National Social Science Funding Project (20BRK039). References Agustí A, Celli BR, Criner GJ, et al. Global Initiative for Chronic Obstructive Lung Disease 2023 Report: GOLD Executive Summary. Eur Respir J 2023; 61: 819–37. Effing TW, Vercoulen JH, Bourbeau J, et al. Definition of a COPD self-management intervention: International Expert Group consensus. Eur Respir J 2016;48: 46–54. Lan X, Lu X, Yi B, Chen X, Jin S. Factors associated with self-management behaviors of patients with chronic obstructive pulmonary disease. Jpn J Nurs Sci 2022;19: e12450. Amico KR, Toro-Alfonso J, Fisher JD. 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Wang H, Wang X, Chen P, et al. Effect of Health Intervention via Web-Based Education on Improving Information-Motivation-Behavioral Skills Related to HPV Vaccination Among Chinese Female College Students. Int J Public Health 2023;68:1605596. Aboumatar H, Garcia Morales EE, Jager LR, et al. Comparing Self-Management Programs with and without Peer Support among Patients with Chronic Obstructive Pulmonary Disease: A Clinical Trial. Ann Am Thorac Soc 2022;19:1687–96. O'Toole J, Krishnan M, Riekert K, Eakin MN. Understanding barriers to and strategies for medication adherence in COPD: a qualitative study. BMC Pulm Med 2022; 22:98. Greene J, Hibbard JH. Why does patient activation matter? An examination of the relationships between patient activation and health-related outcomes. J Gen Intern Med 2012; 27:520–6. Tables Table 1 to 4 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table14.doc Cite Share Download PDF Status: Published Journal Publication published 26 Jul, 2025 Read the published version in npj Primary Care Respiratory Medicine → Version 1 posted Editorial decision: Revision requested 22 May, 2025 Reviews received at journal 19 May, 2025 Reviews received at journal 15 May, 2025 Reviewers agreed at journal 13 May, 2025 Reviewers agreed at journal 13 May, 2025 Reviewers agreed at journal 06 May, 2025 Reviewers invited by journal 28 Apr, 2025 Editor assigned by journal 22 Apr, 2025 Submission checks completed at journal 22 Apr, 2025 First submitted to journal 20 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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16:10:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":978161,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6489153/v1/0b5e6153-dac5-46a6-8f61-5963ef04c0a7.pdf"},{"id":82152868,"identity":"1eb3ae64-4e45-4e3f-b64c-7f9280f8edab","added_by":"auto","created_at":"2025-05-07 07:23:56","extension":"doc","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":201728,"visible":true,"origin":"","legend":"","description":"","filename":"Table14.doc","url":"https://assets-eu.researchsquare.com/files/rs-6489153/v1/1cd6c7e254abfbb485eab2a3.doc"}],"financialInterests":"No competing interests reported.","formattedTitle":"The vision of older COPD patients with different knowledge and motivations:a qualitative study to understand the barriers and recommendations to improving self-management","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChronic obstructive pulmonary disease (COPD) is a chronic respiratory disease with no cure that can cause a range of symptoms including dyspnea, cough, expectoration and systemic inflammation, especially in the elderly [1].\u003csup\u003e\u0026nbsp;\u003c/sup\u003eSelf-management has been advocated for mitigating disease progression, curbing medical costs, and enhancing health-related quality of life among COPD patients [2]. Despite the prevalent reports on the benefits of self-management, COPD patients continue to exhibit a suboptimal level of self-management skills. In China, approximately 50% of COPD patients demonstrated low to moderate overall self-management abilities [3]. The factors contributing to this status are many and likely include the knowledge of self-management and the motivation to implement it, as advocated by the Information-Motivation-Behavioral skills (IMB) model:as individuals acquire knowledge regarding health management strategies and their motivation intensifies, they progressively master and refine the behavioral skills required for positive transformation. In essence, the IMB model highlights the pivotal role of these three components in fostering a proactive stance towards health management (Figure 1) [4].\u003csup\u003e\u0026nbsp;\u003c/sup\u003eAmong COPD patients exhibiting suboptimal self-management behaviors, a subset may possess limited self-management knowledge, some may be devoid of motivation for sustained self-care, while others may experience both these deficiencies. Nevertheless, the self-management experiences and barriers faced by COPD patients lacking either information, motivation, or both, may vary significantly. Drawing upon the core elements of the IMB model, we can categorize these patients into three distinct groups: low-information and low motivation, high information but low motivation, and low- information but strong motivation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eQualitative research may help improve the quality of care that people receive through providing a detailed and nuanced picture of their experiences. However, previous studies have primarily focused on exploring the experiences and barriers of self-management among COPD patients [5,6]. An in-depth analysis of patients with varying factors of self-management barriers (such as three distinct groups above) and the differences in their self-management experiences and barriers has not been conducted.\u003c/p\u003e\n\u003cp\u003eIn this study, we aimed to identify opportunities for improving care based on the experiences and perspectives of different types of COPD patients with suboptimal self-management behaviors. The recommendations for different types of COPD patients may vary, and such targeted advice may yield better results.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design, Participants, and Settings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted ethnographic observations and semi-structured interviews with patients aged 40 years and older who had been diagnosed with stable COPD, and hospitalized in a comprehensive hospital located in southwest China, a region reporting the highest prevalence of COPD (20.2% compared to 15.6% in Northeast China and 13.6% in Northwest China) [7]. We identified participants via a data query that provided the contact information for individuals had been hospitalized for COPD, and called them to make an appointment. Purposive sampling captured a diverse sample in terms of gender and place of residence. The Medical Ethical Committee of the Medical Center Hospital of Qionglai city approved the study (NO 202356).We have informed the participants of the purpose and significance of the study, and obtained the participants\u0026apos; consent and signed the informed consent form. We confirmed that all methods were performed in accordance with the relevant guidelines and regulations, and all procedures were performed in accordance with the Declaration of Helsinki. We used consolidated criteria for reporting qualitative research (COREQ) to guide the design and reporting of this study [8].\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003csup\u003e \u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted semi-structured interviews for 34 participants in the hospital and over 1000 hours of ethnographic observations for additional 30 participants in their home from April 2022 to February 2024. Initially, we assessed participants\u0026apos; knowledge of COPD self-management, which encompassed daily medication adherence, recognition and management of acute exacerbation, oxygen therapy, physical exercise regimens, and respiratory function training. Following this, we administered the Patient Activation Measure 13 (PAM-13) to evaluate their level of patient activation, thereby assessing their motivation. Based on their knowledge and motivation, we categorized the participants into three distinct groups (patient selection and classification procedures:Figure2). Then, we conducted 34 semi-structured interviews with participants, and were conducted in Chinese by three female nurses (XCM, MD; NYW, BS; JL, BS), who have received training in qualitative study and have extensive experience in interviews, through face-to-face communication. The interview guide (Table 1) was developed based on a literature review of COPD self-management [9,10]. The entire interview process adhered strictly to principles of voluntary participation and confidentiality, taking place in a serene and undisturbed environment conducive to candid sharing. The interviews ranged from 15 to 60 minutes, were fully recorded by voice recorder, and promptly transcribed within 24 hours, and transcribed documents were returned to the participants for confirmation. Follow-up interviews were conducted to address any gaps, and data collection ceased once saturation was achieved. Researchers actively prompted participants to articulate their authentic experiences and sentiments. Subsequently, ethnographic observations were conducted in the homes of 30 participants after the semi-structured interviews. Observations focused on daily self-management behaviors and motivations, and consisted of respiratory function exercise, inhalant use, home oxygen therapy, physical activity, and diet. The general focus of work occurring in these homes for about 12 days per site. This enables us to gain a deeper insight into the participants\u0026apos; self-management implementation, encompassing the specifics and accuracy of execution. Furthermore, it facilitates the distinct differentiation between active and passive execution, along with an analysis of the correctness and intensity of these two distinct modes of execution. Fieldwork consisted of over 1000 hours of observations and informal conversations with 30 patients and their family members. Fieldnotes were written up into Word documents.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe used the software NVivo 11.0 for data analysis and Excel for data management. All interviews were tape recorded and transcribed verbatim. Two authors, each equipped with expertise in social and respiratory medicine, and having undergone rigorous qualitative research training, reviewed and coded the transcripts. We used content analysis for data analysis, including reading the transcribed materials carefully to identify meaningful units, code them and generate themes, coding and analysis was performed according to the principles of thematic analysis. During the process of data analysis, two authors independently completed the task of identifying broad description categories. The two authors discussed their observations in depth, classified the data according to related emerging topics, and then improved the codes together. When it is possible to make other explanations, a third author will be consulted to reach consensus. Finally, a list of categories and subcategories was made [11]. The findings of our topic were fed back to the participants.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipants\u0026rsquo; characteristics \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e64 individuals participated in the study. 25 participants were classified as individuals with inadequate information and low motivation, and only 2 participants reported a relatively high educational level. In groups of participants with ample information but insufficient motivation, consisting of 19 individuals, and 7 participants reported a relatively high educational level. However, among participants with limited information but strong motivation (consisting of 20 individuals), approximately 11 members reported having a moderate education level ( Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThemes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe developed 6 main themes that reflect experiences with barriers to self-management (Table 3). Each theme includes examples with additional detail about participants\u0026rsquo; qualitative experiences. However, significant differences in self-management experiences exist in the three groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerspectives of low-information and low motivation group\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;1:\u003c/strong\u003e\u003cstrong\u003elack of self-management knowledge\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe limited self-management capabilities of these patients stem primarily from a deficiency in self-management knowledge. This stems from their relatively weak educational backgrounds or rural residences, which collectively hinder their access, acquisition, and comprehension of health-related information. Notably, some patients reported never having received formal self-management education, particularly those who have not been hospitalized for COPD or undergone standardized COPD treatment.\u003c/p\u003e\n\u003cp\u003eFurther examination reveals that these patients predominantly adopt a passive learning approach, lacking the motivation to actively seek health knowledge from diverse sources, thereby constraining the expansion of their knowledge base. Compounding this issue, some patients indicate that healthcare providers often deliver relevant management information only during times of disease exacerbation or active treatment, resulting in reduced immediacy of knowledge absorption and long-term retention.\u003c/p\u003e\n\u003cp\u003eMoreover, even when patients initially demonstrate proficiency in skills and knowledge, age and disease-related memory decline impedes their ability to sustainably retain this information over time, ultimately affecting the consistency and effectiveness of their self-management capabilities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 2: weak motivation of self-management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe self-management motivation of such COPD patients is notably inadequate, which can be attributed to the combined effects of multiple cognitive and emotional factors. Specifically, some patients fail to fully recognize the potential harm of COPD and the pivotal role of self-management in disease control due to their low frequency of acute exacerbation and mild symptoms. Others tend to overly rely on pharmacotherapy while neglecting the positive effects of self-management. Another group of patients, plagued by recurrent and severe symptoms, experienced intense feelings of frustration and hopelessness, leading to weakened will to survive and subsequent passive attitudes, refusing or struggling to adhere to medical protocols and daily self-management tasks. Furthermore, some patients have adapted to COPD symptoms, establishing a lifestyle that coexists with the disease, lacking the motivation to alter their status quo to meet stricter disease management requirements.\u003c/p\u003e\n\u003cp\u003eThis population is often constrained by lower levels of education and their rural residency, resulting in generally limited self-management abilities and a pronounced reliance on external support, particularly the long-term dependence on healthcare providers. In the realm of health management, they exhibited a heavy reliance on the guidance and intervention of professional medical personnel. Moreover, due to a lack of recognition of their active role in disease management, these patients tend to underestimate their self-efficacy, leading to passive self-management behaviors that hinder their proactive engagement in health maintenance and disease management processes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerspectives of high information but low motivation group\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 1: unsatisfactory absorption of knowledge\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis group is primarily concentrated among those with higher cultural literacy who have long resided in urban environments. They have extensively and deeply delved into the knowledge and information in the field of health management through diversified channels. However, due to the abundance of information sources and the vast amount of information, this segment of the population may encounter the problem of information overload when confronted with intricate and complex health information, subsequently leading to feelings of confusion and disorientation. Furthermore, given their tendency towards rigorous and meticulous behavior, some patients may exhibit a heightened focus and pursuit of details in health management practices, potentially even slipping into an excessive obsession with the minutiae of health management, thereby neglecting the effectiveness and sustainability of overall health management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 2:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eunwillingness to self-management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis group possesses relatively abundant knowledge about the specific medical condition, yet they lack the motivation to engage in self-management. Unlike patients with inadequate information and low motivation, this group fully acknowledges the incurability of COPD, hence firmly believing that self-management is futile. On the other hand, some patients are unable to meet the demands of self-management due to their difficulty in altering existing lifestyle habits.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerspectives of low- information but strong motivation group\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 1: low-efficiency knowledge form\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis patient population was predominantly concentrated in rural areas and generally possessed a moderate level of education. Despite the fact that some patients did not fully acquire the relevant knowledge system for self-management, they exhibited a profound aspiration for good health, manifested in a strong willingness and motivation to engage in self-management practices. Consequently, they tend to actively seek knowledge and skills related to self-management through diverse channels. However, due to a relative lack of rational evaluation capabilities, the information acquired in this process may be inaccurate or unscientific, potentially posing a threat to the effectiveness and safety of their self-management efforts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 2: excessive activation state\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis group demonstrated a pronounced level of concern and proactive approach towards their own health status, evidenced by their robust execution of health behaviors. They actively seek and integrated diverse resources to acquire knowledge and skills for self-management and health promotion. Once equipped with these skills, they tend to maintain consistent implementation over time. Nevertheless, it was noteworthy that this group exhibited a relatively weak capacity in evaluating the authenticity of health information, rendering them susceptible to non-expert or misleading external opinions during the information acquisition and execution process. Consequently, they may adopt and followed inaccurate or unscientific health guidelines, posing additional challenges for healthcare professionals in assessing the effectiveness of their self-management efforts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparisons of experience among three groups\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEach displaying unique differences in health information and self-management motivation, as illustrated in Figure 3. Specifically, for patients who lack both information and motivation, the core issue is limited understanding of COPD or inability to effectively comprehend and retain health-related knowledge, which may also significantly contribute to their low motivation. Conversely, patients who have limited access to information but exhibit strong motivation face the primary challenge of easily adopting and implementing inaccurate or unscientific health information, which may potentially exacerbate their symptoms. Their high level of self-management motivation actually increases the likelihood of persisting in erroneous behavioral patterns. As for patients who are well-informed but lack motivation, despite possessing sufficient knowledge of treatment and health management, it is precisely this knowledge base that may lead them to overly focus on minor physical changes and psychologically magnify these changes, potentially resulting in anxiety. This classification highlights the importance of tailored interventions to address the specific challenges faced by each patient type in order to improve COPD care and management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrategies to optimize self-management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eComparison of the results of three types of COPD patients and some promising strategies to optimize self-management of them. Table 4 gives a description of the identified strategies, the problem they aim to overcome. Based on a comprehensive analysis, we identified several key aspects: the necessity of an initial assessment of self-management knowledge and motivation; For those with insufficient information and low motivation, it is highly necessary to provide essential knowledge through channels such as popular science education and free consultations, and implement cognitive rehabilitation and memory compensation strategies for patients with memory decline. For those proficient in knowledge yet lacking motivation, we prioritize bolstering motivation through peer support networks or familial oversight. For patients with scarce information yet robust motivation, ensuring access to precise knowledge or verification pathways is vital. Regular follow-ups and fostering family involvement in monitoring are crucial to prevent the acquisition of erroneous information.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study yielded several barriers that influence self-management of different types of COPD patients based on the information-motivation-behavioral skills model. We found that different types of COPD patients have different experiences of self-management disorder, and we identified strategies to optimize competencies of different types of COPD patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe discern those with inadequate information and low motivation exhibited distinct challenges in navigating barriers to self-care practices, as compared to individuals with abundant information but sufficient motivation. As posited by Hibbard and colleagues, low-activation patients exhibited marked deficits in health literacy, management skills, and valuing self-care, hence termed \u0026quot;passive patients [12].\u003csup\u003e\u0026nbsp;\u003c/sup\u003eThis underscores the need for tailored interventions that not only enhance informational access but also motivate and empower such individuals to actively engage in their health. Hence, patients with low activation exhibit suboptimal health knowledge, skills, and beliefs, with disparities rooted in distinct experiences. Notably, those with inadequate information and low motivation predominantly reside in lower-educated or rural settings, lacking systematic education, which resulted in limited comprehension of disease management, mirroring prior findings [5].\u003csup\u003e\u0026nbsp;\u003c/sup\u003eIn addition, another study confirmed that COPD patients were prone to cognitive impairment, and the incidence of cognitive impairment in patients with COPD can be up to 56.5%[13]. COPD patients often experience impairments in attention, memory, and executive functions, pivotal for self-management. This manifests in poor communication with healthcare providers, hindering information reception. Memory deficits further compromise long-term retention of health knowledge, undermining patients\u0026apos; ability to apply acquired information [14].\u003csup\u003e\u0026nbsp;\u003c/sup\u003eTherefore, patients with COPD often lack effective knowledge about health management. According to the IMB model, it can be deduced that information can influence motivation [15].\u003csup\u003e\u0026nbsp;\u003c/sup\u003eWe can understand it as: when patients lack sufficient health knowledge, their beliefs, confidence, and actions in carrying out healthy behaviors will be significantly lacking. Consequently, patients will demonstrate specific behaviors related to a weak motivation for self-management, \u0026nbsp;manifesting as fatalistic views or reluctance to adjust lifestyles. Strengthening self-management knowledge is paramount, achieved via science popularization, medical consultations, and for memory-impaired patients, memory strategies or cognitive training.\u003c/p\u003e\n\u003cp\u003eOur findings indicated that patients with sufficient knowledge but lacking motivation were predominantly those with some cultural awareness or are relatively youthful. \u0026nbsp;Despite familiarity with COPD self-management, their motivation remains low, possibly due to a perceived incurability and belief that self-management efforts are futile. These entrenched beliefs hinder agreement with medical advice. However, peer support has been effective in enhancing compliance with self-management, as they tend to resonate with shared experiences from those in similar circumstances [16].\u003csup\u003e\u0026nbsp;\u003c/sup\u003eTherefore, engaging COPD patients who excel in self-management to share their positive experiences could bolster the motivation of informed yet unmotivated patients. Additionally, fostering family involvement in overseeing and supporting the patient\u0026apos;s self-management practices is pivotal to enhancing overall outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsistent with our study, notable disparities emerged in the self-management experiences of COPD patients based on their informational and motivational profiles. Specifically, those with inadequate information and low motivation, as well as those with limited information but strong motivation, confronted comparable challenges in health literacy, notably the scarcity of health information. Prior research echoes this, highlighting unclear inhaler instructions and inadequate communication between healthcare providers and patients as primary barriers to compliance, further underlining the need for targeted interventions to address these gaps [17].\u003csup\u003e\u0026nbsp;\u003c/sup\u003ePatients with limited information but strong motivation exhibited elevated levels of activation, resulting in superior overall execution capabilities. Notably, they proactively utilized tools to compensate for memory deficits, sought diverse information sources to address their health knowledge gaps, and seamlessly integrated disease management into their daily routines, fostering habit formation. Another study also demonstrated that higher patient activation levels positively correlate with engagement in health-promoting behaviors [12]. In addition, patients with high motivation were more likely to obtain the information they need from healthcare providers [18]. Despite their heightened motivation, and proficiency in maintaining healthy habits, these patients faced a significant disadvantage:an inability to critically assess the veracity of information, leading them to readily accept others\u0026apos; opinions and potentially perpetuate incorrect health behaviors over time. This predicament posed a formidable challenge for healthcare professionals, who were tasked with delivering scientific, and tailored health education while also monitoring patients\u0026apos; adherence to evidence-based practices. Consequently, it was imperative to empower these patients with the means to discern knowledge accuracy and to encourage familial support in monitoring their behaviors, thereby mitigating the risk of unscientific practices.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are limitations to this study. First, various regions of China are not homogeneous, and our findings should not be generalized to all patients with COPD. Second, the interviews with a few inactive interviewees were short. They were reticent to share their thoughts about the topic. We employed a convenience sampling method, which may have led to selection bias in the study subjects.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusions","content":" \u003cp\u003eDrawing upon the IMB model, the suboptimal self-management behaviors observed among COPD patients can be categorized into three distinct types, each with unique experiences of encountering barriers to self-care. We propose the adoption of tailored improvement measures specific to each type of COPD patient. By offering targeted health education or enhancement strategies that are grounded in patients' individual types and their respective self-management challenges, we can foster an environment conducive to the enhancement of patients' self-management capabilities.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eor Contributors\u003c/strong\u003e XMC, NYW, JL conducted the data collection and analysis and produced the initial draft of the manuscript. YXH and LW implemented the intervention and commented on drafts. RZ reviewed and commented on drafts. YNY is the qualitative lead and overall guarantor, conducted analysis and reviewed and edited the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement:\u003c/strong\u003e Data are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest Disclosures:\u003c/strong\u003e No conflict of interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient consent for publication:\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e This study involves human participants and was approved by the Medical Ethical Committee of the Medical Center Hospital of Qionglai city approved the study (NO 202356). Participants gave informed consent to participate in the study before taking part. We confirmed that all methods were performed in accordance with the relevant guidelines and regulations, and all procedures were performed in accordance with the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding/Support:\u0026nbsp;\u003c/strong\u003eThis study was supported by National Social Science Funding Project (20BRK039).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAgust\u0026iacute; A, Celli BR, Criner GJ, et al. Global Initiative for Chronic Obstructive Lung Disease 2023 Report: GOLD Executive Summary. Eur Respir J 2023; 61: 819\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEffing TW, Vercoulen JH, Bourbeau J, et al. Definition of a COPD self-management intervention: International Expert Group consensus. Eur Respir J 2016;48: 46\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLan X, Lu X, Yi B, Chen X, Jin S. Factors associated with self-management behaviors of patients with chronic obstructive pulmonary disease. Jpn J Nurs Sci 2022;19: e12450.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmico KR, Toro-Alfonso J, Fisher JD. An empirical test of the information, motivation and behavioral skills model of antiretroviral therapy adherence. AIDS Care 2005;17: 661\u0026ndash;673.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYadav UN, Lloyd J, Hosseinzadeh H, et al. Facilitators and barriers to the self-management of COPD: a qualitative study from rural Nepal. BMJ Open 2020;10: e035700.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO'Toole J, Krishnan M, Riekert K, Eakin MN. Understanding barriers to and strategies for medication adherence in COPD: a qualitative study. BMC Pulm Med 2022; 22: 98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFang L, Gao P, Bao H, et al. Chronic obstructive pulmonary disease in China: a nationwide prevalence study. Lancet Respir Med 2018; 6: 421\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care 2007; 19: 349\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCravo A, Attar D, Freeman D, Holmes S, Ip L, Singh SJ. The Importance of Self-Management in the Context of Personalized Care in COPD. Int J Chron Obstruct Pulmon Dis 2022; 17: 231\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchrijver J, Lenferink A, Brusse-Keizer M, et al. Self-management interventions for people with chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2022;1: CD002990.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeng L, Shi Z, Chai XY, Nie HW, Cong HB, Li SP. Patient and clinician perspectives on shared decision-making in infertility treatment: A qualitative study. Patient Educ Couns 2023;116: 107948.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHibbard JH, Stockard J, Mahoney ER, Tusler M. Development of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Serv Res 2004; 39:1005\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen X, Dong X, Liu J, Liu X, Deng M, Yang Y. Rural-Urban Differences in Mild Cognitive Impairment Among Patients with Chronic Obstructive Pulmonary Disease in ChengDu, China. Int J Chron Obstruct Pulmon Dis 2023;18:2497\u0026ndash;508.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaird C, Lovell J, Johnson M, Shiell K, Ibrahim JE. The impact of cognitive impairment on self-management in chronic obstructive pulmonary disease: A systematic review. Respir Med 2017; 129:130\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang H, Wang X, Chen P, et al. Effect of Health Intervention via Web-Based Education on Improving Information-Motivation-Behavioral Skills Related to HPV Vaccination Among Chinese Female College Students. Int J Public Health 2023;68:1605596.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAboumatar H, Garcia Morales EE, Jager LR, et al. Comparing Self-Management Programs with and without Peer Support among Patients with Chronic Obstructive Pulmonary Disease: A Clinical Trial. Ann Am Thorac Soc 2022;19:1687\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO'Toole J, Krishnan M, Riekert K, Eakin MN. Understanding barriers to and strategies for medication adherence in COPD: a qualitative study. BMC Pulm Med 2022; 22:98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreene J, Hibbard JH. Why does patient activation matter? An examination of the relationships between patient activation and health-related outcomes. J Gen Intern Med 2012; 27:520\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 to 4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"npj-primary-care-respiratory-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"npjpcrm","sideBox":"Learn more about [npj Primary Care Respiratory Medicine](https://www.nature.com/npjpcrm/)","snPcode":"41533","submissionUrl":"https://submission.springernature.com/new-submission/41533/3","title":"npj Primary Care Respiratory Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"NPJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Older COPD patients, knowledge, motivations, qualitative study","lastPublishedDoi":"10.21203/rs.3.rs-6489153/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6489153/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003eTo explore opportunities for improving care based on the experiences and perspectives of different types of COPD patients based on the Information-Motivation-Behavioral skills (IMB) model with poor self-management behaviors\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003eWe used ethnographic methods(over 1000 hours of observations for 30 participants), and conducted 34 semi-structured interviews with different types of COPD patients. Data were analysed using inductive thematic analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eAccording to the IMB model, we divide participants into three categories, namely low-information and low motivation group, high information but low motivation group and low- information but strong motivation group. In the first group, due to the single source of information and decreased memory capacity. Also, patients showed a low perceived threat of disease and negation of self-management value, which led to the lack of self-management knowledge and motivation for this group of patients. In the second group, patients were pessimistic about the cure of the disease because of too much information or too much attention to the details of knowledge, which was also the reason why patients were unwilling to implement the self-management although they had mastered enough knowledge. The third type of patients, with strong motivation, would seek health information resources through various channels. Because of this, they could easily catch incorrect or unscientific information, which would make the situation worse.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003eThis qualitative study suggest COPD patients exhibit distinct self-management experiences, barriers, and recommendations due to variations in information processing and motivational characteristics. Future research should tailor precise self-management strategies based on individual patient profiles.\u003c/p\u003e","manuscriptTitle":"The vision of older COPD patients with different knowledge and motivations:a qualitative study to understand the barriers and recommendations to improving self-management","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-07 07:07:51","doi":"10.21203/rs.3.rs-6489153/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-22T11:48:43+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-19T15:13:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-15T10:09:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"81070341393045227443874980013127273107","date":"2025-05-13T09:51:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"178863925088391936979230986981659676240","date":"2025-05-13T09:38:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"214356622957370001166958763438542011730","date":"2025-05-06T15:16:31+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-28T15:52:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-22T07:53:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-22T07:49:03+00:00","index":"","fulltext":""},{"type":"submitted","content":"npj Primary Care Respiratory Medicine","date":"2025-04-20T12:00:08+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"npj-primary-care-respiratory-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"npjpcrm","sideBox":"Learn more about [npj Primary Care Respiratory Medicine](https://www.nature.com/npjpcrm/)","snPcode":"41533","submissionUrl":"https://submission.springernature.com/new-submission/41533/3","title":"npj Primary Care Respiratory Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"NPJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f47cd519-1c73-45aa-9ece-e36c05dc8af4","owner":[],"postedDate":"May 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":47804162,"name":"Health sciences/Diseases"},{"id":47804163,"name":"Health sciences/Health care"}],"tags":[],"updatedAt":"2025-07-28T16:07:05+00:00","versionOfRecord":{"articleIdentity":"rs-6489153","link":"https://doi.org/10.1038/s41533-025-00443-9","journal":{"identity":"npj-primary-care-respiratory-medicine","isVorOnly":false,"title":"npj Primary Care Respiratory Medicine"},"publishedOn":"2025-07-26 15:58:22","publishedOnDateReadable":"July 26th, 2025"},"versionCreatedAt":"2025-05-07 07:07:51","video":"","vorDoi":"10.1038/s41533-025-00443-9","vorDoiUrl":"https://doi.org/10.1038/s41533-025-00443-9","workflowStages":[]},"version":"v1","identity":"rs-6489153","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6489153","identity":"rs-6489153","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}