Research Article| Volume 55, P1-10, September 2022

Nonadherence to health promotion depending on chronic obstructive pulmonary disease severity


      • The current national diagnostic rate and awareness for early diagnosis and treatment for COPD is still low.
      • COPD patients with more stress and comorbidities are more likely to show nonadherence to health behaviors.
      • Nonadherence to health behaviors is higher in moderate and severe COPD groups than in the mild COPD group, so it is necessary to tailor healthcare steps to the severity of the disease.



      Nonadherence to recommended health behaviors reportedly correlates with the prevalence and health outcomes of COPD, but the factors contributing to multiple health promotions are not well understood.


      To examine the factors associated with nonadherence to health behaviors, specifically focusing on COPD severity.


      We conducted a secondary data analysis with data from the 2016–2019 Korea National Health and Nutrition Examination Survey. The analyzed data were from 1,627 individuals aged over 40 years who had a FEV1/FVC ratio < 70% measured via spirometer. In this study, nonadherence to health behaviors is the sum of seven health-promoting behaviors in terms of smoking cessation, alcohol abstinence, regular exercise, weight control, recommended sleep time, influenza vaccination, and medical check-up.


      COPD patients’ nonadherence to health behaviors was significantly associated with comorbidity (p=0.017), stress (p=0.002), and COPD severity (moderate, severe; p=0.010, p=0.039, respectively). In addition, the moderate and severe COPD groups showed a higher nonadherence rate than the mild COPD group. Specifically, nonadherence to weight control was the most significantly different behavior according to COPD severity levels, based on the GOLD classification of airflow limitation.


      Our study findings support that those with higher levels of stress, comorbidities, and severe disease conditions are less likely to adhere to health behaviors. Thus, healthcare providers and policymakers should provide tailored approaches according to COPD severity to educate and support appropriate health behaviors for individuals with COPD.



      COPD (Chronic obstructive pulmonary disease), KNHANES (Korea National Health and Nutrition Examination Survey), GOLD (Global Initiative for Chronic Obstructive Lung Disease)
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        • Halpin DM
        • Miravitlles M.
        Chronic obstructive pulmonary disease: the disease and its burden to society.
        Proceedings of the American Thoracic Society. 2006; 3: 619-623
        • Miravitlles M
        • Ribera A.
        Understanding the impact of symptoms on the burden of COPD.
        Respiratory Research. 2017; 18: 1-11
      1. World Health Organization.
        World Health Statistics 2008 [Internet]. World Health Organization, 2008 (Available from)
      2. The Korean Academy of Tuberculosis and Respiratory Diseases. Korean guidelines for COPD 2018 revision [Internet]. The Korean Academy of Tuberculosis and Respiratory Diseases; 2018 Feb. Available from:

        • Park H
        • Jung SY
        • Lee K
        • et al.
        Prevalence of chronic obstructive lung disease in Korea using data from the fifth Korea national health and nutrition examination survey.
        Korean Journal of Family Medicine. 2015; 36: 128-134
        • Kaplan A
        • Thomas M.
        Screening for COPD: the gap between logic and evidence.
        European Respiratory Review. 2017; 26
        • Gershon AS
        • Thiruchelvam D
        • Chapman KR
        • et al.
        Health services burden of undiagnosed and overdiagnosed COPD.
        Chest. 2018; 153: 1336-1346
        • Jeon C
        • Oh K.
        Prevalence of chronic obstructive pulmonary disease among adults over 40 years old in Korea, 2009-2013.
        Public Health Weekly Report, KCDC. 2015; 8 (Available from:): 334-336
        • Ho T
        • Cusack RP
        • Chaudhary N
        • Satia I
        • Kurmi OP.
        Under-and over-diagnosis of COPD: a global perspective.
        Breathe. 2019; 15: 24-35
        • Pocket guide to COPD diagnosis, management, and prevention
        Global initiative for chronic obstructive lung disease. [Internet].
        Global Initiative for Chronic Obstructive Lung Disease. 2020; (Available from:)
        • Stang P
        • Lydick E
        • Silberman C
        • Kempel A
        • Keating ET.
        The prevalence of COPD: using smoking rates to estimate disease frequency in the general population.
        Chest. 2000; 117: 354S-359S
        • Tabak C
        • Smit HA
        • Räsänen L
        • et al.
        Alcohol consumption in relation to 20-year COPD mortality and pulmonary function in middle-aged men from three European countries.
        Epidemiology. 2001; 12: 239-245
        • Silva CMDSE
        • Gomes Neto M
        • Saquetto MB
        • Conceição CSD
        • Souza-Machado A
        Effects of upper limb resistance exercise on aerobic capacity, muscle strength, and quality of life in COPD patients: a randomized controlled trial.
        Clinical Rehabilitation. 2018; 32: 1636-1644
        • Harik-Khan RI
        • Fleg JL
        • Wise RA.
        Body mass index and the risk of COPD.
        Chest. 2002; 121: 370-376
        • Clari M
        • Matarese M
        • Ivziku D
        • De Marinis MG.
        Self-care of people with chronic obstructive pulmonary disease: a meta-synthesis.
        The Patient-Patient-Centered Outcomes Research. 2017; 10: 407-427
        • Moriarty HJ
        • Deatrick JA
        • Mahon MM
        • et al.
        Issues to consider when choosing and using large national databases for research of families.
        Western Journal of Nursing Research. 1999; 21: 143-153
        • Andersen RM.
        Revisiting the behavioral model and access to medical care: does it matter?.
        Journal of Health and Social Behavior. 1995; : 1-10
        • Babitsch B
        • Gohl D
        • Von Lengerke T.
        Re-revisiting Andersen's Behavioral Model of Health Services Use: a systematic review of studies from 1998–2011.
        GMS Psycho-Social-Medicine. 2012; 9
      3. Ministry of health and welfare. [Internet]. Available from:

        • Mcsharry DG
        • Ryan S
        • Calverley P
        • Edwards JC
        • Mcnicholas WT.
        Sleep quality in chronic obstructive pulmonary disease.
        Respirology. 2012; 17: 1119-1124
        • Alfageme I
        • Vazquez R
        • Reyes N
        • et al.
        Clinical efficacy of anti-pneumococcal vaccination in patients with COPD.
        Thorax. 2006; 61: 189-195
        • An TJ
        • Yoon HK.
        Prevalence and socioeconomic burden of chronic obstructive pulmonary disease.
        J Korean Med Assoc. 2018; 61: 533-538
        • Centers for Disease Control and Prevention
        Defining adult overweight & obesity [Internet].
        Centers for Disease Control and Prevention. 2021; Mar (Available from:)
        • Hirshkowitz M
        • Whiton K
        • Albert SM
        • et al.
        National Sleep Foundation's sleep time duration recommendations: methodology and results summary.
        Sleep Health. 2015; 1: 40-43
        • Lynn MR.
        Determination and quantification of content validity.
        Nursing Research. 1986; 35: 382-385
        • Polit DF
        • Beck CT.
        The content validity index: are you sure you know what’s being reported? Critique and recommendations.
        Research in Nursing & Health. 2006; 29: 489-497
        • Little RJ.
        A test of missing completely at random for multivariate data with missing values.
        Journal of the American Statistical Association. 1988; 83: 1198-1202
        • West SG
        • Finch JF
        • Curran PJ.
        Structural equation models with nonnormal variables: problems and remedies.
        Structural Equation Modeling: Concepts, Issues, and Applications. Sage Publications, Inc, Thousand Oaks, CA, US1995: 56-75
        • Yang H
        • Wang H
        • Du L
        • Wang Y
        • Wang X
        • Zhang R.
        Disease knowledge and self-management behavior of COPD patients in China.
        Medicine. 2019; 98
        • O’Conor R
        • Muellers K
        • Arvanitis M
        • et al.
        Effects of health literacy and cognitive abilities on COPD self-management behaviors: a prospective cohort study.
        Respiratory Medicine. 2019; 160105630
        • Gauthier A
        • Bernard S
        • Bernard E
        • Simard S
        • Maltais F
        • Lacasse Y.
        Adherence to long-term oxygen therapy in patients with chronic obstructive pulmonary disease.
        Chronic Respiratory Disease. 2019; 16
        • Katsenos S
        • Constantopoulos SH.
        Long-term oxygen therapy in COPD: factors affecting and ways of improving patient compliance.
        Pulmonary Medicine. 2011; 2011
        • Miravitlles M
        • Soriano JB
        • Garcia-Rio F
        • et al.
        Prevalence of COPD in Spain: impact of undiagnosed COPD on quality of life and daily life activities.
        Thorax. 2009; 64: 863-868
        • Blanco I
        • Diego I
        • Bueno P
        • et al.
        Geographical distribution of COPD prevalence in Europe, estimated by an inverse distance weighting interpolation technique.
        International Journal of Chronic Obstructive Pulmonary Disease. 2017; 13: 57-67
        • Gershon AS
        • Mecredy GC
        • Guan J
        • Victor JC
        • Goldstein R
        • To T.
        Quantifying comorbidity in individuals with COPD: a population study.
        European Respiratory Journal. 2015; 45: 51-59
        • Wang C
        • Xu J
        • Yang L
        • et al.
        Prevalence and risk factors of chronic obstructive pulmonary disease in China (the China pulmonary health [CPH] study): a national cross-sectional study.
        The Lancet. 2018; 391: 1706-1717
        • Kang G-J
        • Kim M-H
        • Hwang S-K.
        Self-care, symptom experience, and health-related quality of life by COPD severity.
        Korean Journal of Adult Nursing. 2008; 20: 163-175
        • Li J
        • Zhu L
        • Wei Y
        • et al.
        Association between adiposity measures and COPD risk in Chinese adults.
        European Respiratory Journal. 2020; 55
        • Lee KH.
        Nutritional Assessment in patients with chronic obstructive pulmonary disease.
        Tuberculosis and Respiratory Diseases. 2005; 59: 242-249
        • Fisher EB
        • Fitzgibbon ML
        • Glasgow RE
        • et al.
        Behavior matters.
        American Journal of Preventive Medicine. 2011; 40: e15-e30
        • Perez-Benzo GM
        • Muellers K
        • Chen S
        • et al.
        Identifying behavioral phenotypes in chronic illness: self-management of COPD and comorbid hypertension.
        Patient Education and Counseling. 2021; 104: 627-633
        • Patnaik JL
        • Byers T
        • DiGuiseppi C
        • Dabelea D
        • Denberg TD.
        Cardiovascular disease competes with breast cancer as the leading cause of death for older females diagnosed with breast cancer: a retrospective cohort study.
        Breast Cancer Research. 2011; 13: 1-9
        • DiMatteo MR
        • Haskard KB
        • Williams SL.
        Health beliefs, disease severity, and patient adherence: a meta-analysis.
        Medical Care. 2007; : 521-528
        • Putcha N
        • Puhan MA
        • Drummond MB
        • et al.
        A simplified score to quantify comorbidity in COPD.
        PloS One. 2014; 9e114438
        • Incalzi RA
        • Corsonello A
        • Pedone C
        • et al.
        Chronic renal failure: a neglected comorbidity of COPD.
        Chest. 2010; 137: 831-837
        • Westerik JA
        • Metting EI
        • van Boven JF
        • Tiersma W
        • Kocks JW
        • Schermer TR.
        Associations between chronic comorbidity and exacerbation risk in primary care patients with COPD.
        Respiratory Research. 2017; 18: 1-17
        • Hillas G
        • Perlikos F
        • Tsiligianni I
        • Tzanakis N.
        Managing comorbidities in COPD.
        International Journal of Chronic Obstructive Pulmonary Disease. 2015; 10: 95
        • Young RP
        • Hopkins RJ.
        Link between COPD and lung cancer.
        Respiratory Medicine. 2010; 104: 758-759
        • Papi A
        • Casoni G
        • Caramori G
        • et al.
        COPD increases the risk of squamous histological subtype in smokers who develop non-small cell lung carcinoma.
        Thorax. 2004; 59: 679-681
        • Stellefson M
        • Paige SR
        • Barry AE
        • Wang MQ
        • Apperson A.
        Risk factors associated with physical and mental distress in people who report a COPD diagnosis: latent class analysis of 2016 behavioral risk factor surveillance system data.
        International Journal of Chronic Obstructive Pulmonary Disease. 2019; 14: 809-822
        • Paine NJ
        • Bacon SL
        • Bourbeau J
        • et al.
        Psychological distress is related to poor health behaviours in COPD and non-COPD patients: evidence from the CanCOLD study.
        Respiratory Medicine. 2019; 146: 1-9
        • Lu Y
        • Nyunt MSZ
        • Gwee X
        • et al.
        Life event stress and chronic obstructive pulmonary disease (COPD): associations with mental well-being and quality of life in a population-based study.
        BMJ Open. 2012; 2e001674
        • Pumar MI
        • Gray CR
        • Walsh JR
        • IA Yang
        • Rolls TA
        • Ward DL.
        Anxiety and depression—important psychological comorbidities of COPD.
        Journal of Thoracic Disease. 2014; 6: 1615
        • Kiliçkaya C
        • Asi Karakaş S.
        The effect of illness perception on loneliness and coping with stress in patients with chronic obstructive pulmonary disease (COPD).
        International Journal of Caring Sciences. 2016; 9: 481
        • Dury R.
        COPD and emotional distress: not always noticed and therefore untreated.
        British Journal of Community Nursing. 2016; 21: 138-141