Chronic Obstructive Pulmonary Disease (COPD) is the most common chronic illness worldwide, with a 12% prevalence and a 5% mortality rate [1]. In Korea, the diagnosis rates of other chronic diseases such as hypertension (71.4%) and diabetes (65.2%) far exceed the diagnosis rate of COPD, which stands at 2.5% [2]. Furthermore, smoking represents a primary cause of COPD, with one study finding that 60.6% of smokers exhibited symptoms of the disease. However, approximately half of these individuals reported not seeking routine medical care, and only 0.4% spontaneously recognized COPD as a respiratory disease [3]. Another study found that even among patients diagnosed with COPD, more than half did not adhere to self-management [4]. Furthermore, only 13.9% of patients were found to use their inhalers correctly while the proper use of treatments such as inhalers is associated with lower hospitalization and mortality rates [5].

The goal of COPD self-management is to empower patients to recognize the value of this practice and actively participate in managing the condition [6]. This involves patients supporting their health through exercise and dietary adjustments, understanding the severity of their symptoms, and communicating these symptoms to healthcare professionals for appropriate treatment [7]. A systematic literature review demonstrated that various COPD self-management interventions enhance patient knowledge, medication adherence, physical activity, and success in smoking cessation [8]. Additionally, a Cochrane systematic review revealed that such interventions can improve quality of life and reduce the risk of respiratory-related hospitalization [9]. Despite these beneficial outcomes, many patients with COPD struggle with adhering to self-management protocols due to insufficient awareness of the disease. They often discontinue their medication once symptoms subside, which can adversely impact not only their physical health, but also their social and psychological well-being [10]. Consequently, strategies to address non-adherence and improve quality of life are necessary [11].

Given that self-management of COPD is a cost-effective strategy for disease treatment, numerous studies have been conducted on the factors influencing adherence and non-adherence [7, 12]. Factors associated with adherence include high education level, low number of comorbidities, strong health beliefs, high satisfaction with inhalers, participation in self-management with professionals, and education on exacerbation and symptom management [13, 14]. Conversely, factors linked to non-adherence include a lack of knowledge and understanding of COPD, frustration with the condition, poor emergency response, and insufficient education by professionals [7, 15]. However, these factors have been infrequently identified, contributing to an absence of comprehensive research investigating the full range of non-adherence factors or the development of a conceptual framework for non-adherence to COPD self-management.

To develop COPD self-management programs having continuous effects, it should preced to identify the crucial causes of non-adherence among patients [15]. However, the complexities of non-adherence behaviors are not fully understood due to ambiguous definitions, inadequate diagnosis, a failure to consider various contributing factors, and a lack of integrated research findings [12]. Consequently, insufficient research has been aimed at developing a conceptual framework by categorizing the factors related to non-adherence in COPD self-management [14, 16].

A conceptual framework is a systematic combination of concepts based on researchers’ reasoning or provisional conclusions, intended to enhance the understanding of phenomena [15]. Expert panel investigations, such as Delphi surveys, are utilized to establish priorities and develop conceptual frameworks in areas that have been insufficiently researched and thus require comprehensive review [17]. This approach facilitates the organization of concepts into hierarchical domains or subdomains. Therefore, it is crucial to develop a framework that comprehensively synthesizes and categorizes factors associated with non-adherence to COPD self-management by identifying both non-adherence and adherence factors and assigning attributes to these concepts [18]. This study classified the factors associated with non-adherence to COPD self-management by incorporating literature reviews, patient perspectives, and expert panel insights, thereby providing a solid theoretical foundation for understanding non-adherence factors.

Accordingly, the purpose of this study was to develop a conceptual framework associated with non-adherence among patients with COPD. This was accomplished using three approaches: a literature review, in-depth interviews with patients, and surveys of healthcare professionals featuring semi-structured open-ended questions.

This study entailed the development of a conceptual framework for understanding non-adherence to self-management among patients with COPD. The framework was constructed by extracting, categorizing, and linking relevant factor categories from a literature review, in-depth patient interviews, and expert surveys featuring semi-structured questions. Its objective was to address gaps in previous research [3, 12] by including factors identified through at least one of the three aforementioned methods as categories and specific factors related to non-adherence. The development and refinement of the conceptual framework were informed by systematic reviews of approximately 100 existing frameworks related to medication adherence [28], as well as frameworks cited in two pieces of literature and recent evidence [29]. Although the number of non-adherence factors identified through patient interviews was limited, the inclusion of factors unique to patients with COPD supports the thoroughness of the framework. Furthermore, the value of this study lies not only in its comprehensive and systematic identification of non-adherence factors but also in the hierarchical structuring of these factors. This approach enhances the understanding of the complex phenomenon of non-adherence to self-management in COPD, which extends beyond issues of medication adherence. The diversity of areas from which non-adherence factors were extracted suggests that this conceptual framework could have broad applications in the development of models for predicting non-adherence and in designing interventions to reduce non-adherence rates.

The study revealed eight categories and 53 factors associated with non-adherence in the self-management of patients with COPD. These categories encompassed personal, socioeconomic, disease-related, psychological, functional, treatment-related, healthcare system-related, and environmental characteristics. While the expert semi-structured interviews yielded factors across all categories, the literature review did not reveal any environmental characteristics, and the in-depth patient interviews uncovered no healthcare system-related factors. Moreover, disease-related and treatment-related characteristics were infrequently identified, with the exceptions being comorbidities, the complexity of treatment, and the number of medications. The absence of environmental characteristics in the literature review suggests that researchers investigating non-adherence factors in COPD self-management have predominantly focused on micro perspectives, such as individual, socioeconomic, psychological, disease, and treatment-related aspects. This trend aligns with studies on non-adherence in the self-management of other chronic diseases, such as hypertension and diabetes [30, 31]. However, relative to other chronic diseases, COPD is more closely associated with environmental factors that influence its onset and progression [32]. Patients with COPD experience significantly more frequent and severe episodes of breathlessness due to weather and their surrounding environment compared to patients with chronic heart failure [33]. This breathlessness often necessitates a restful environment or the use of short acting metered-dose inhalers, thereby exploring the inclusion of environmental characteristics as a category of factors in non-adherence to COPD self-management. Outdoor activities, which are impacted by levels of particulate matter and fine particulate matter [34], further contribute to the inescapable impact of environmental characteristics. Consequently, this study is distinguished from previous research as the first to recognize environmental characteristics as a category of factors contributing to non-adherence.

In-depth one-on-one interviews of patients with COPD revealed no factors related to characteristics of the healthcare system and very few factors related to disease- or treatment-related characteristics. This suggests that patients tend to attribute their non-adherence to self-management to personal characteristics or their immediate environment, indicating a lack of awareness that the healthcare system, disease, or treatment characteristics could influence their non-adherence. Similar findings have emerged from qualitative research involving in-depth interviews with 30 patients with COPD, in which facilitators of medication adherence were identified in the patient’s personal or immediate surroundings, including the use of diaries or visual/temporal cues for medication intake, along with family support. No facilitators related to the healthcare system or disease and treatment were identified from the interviews [35]. This indicates that these patients view themselves as passive recipients of care, not recognizing their active role in treatment. The recent paradigm shift in healthcare, which now recognizes patients as active participants in their treatment rather than solely as service recipients, represents a promising step forward [36]. Specifically, the proactive engagement of patients in COPD management marks a meaningful advancement [36]. However, prior research on the level of activation in self-management among patients with COPD indicated that 23% demonstrated low activation, with only 15% considered “activated” in managing the condition [37]. To encourage those with COPD to actively participate in their treatment, it is crucial that they recognize the potential for improved disease management through enhancements to the hospital system, alleviation of COPD symptoms, and stable treatment. Numerous studies have underscored the importance of disease and treatment characteristics in determining adherence or non-adherence to self-management [6]. Since recognizing factors of non-adherence can lead to increased adherence rates, it is crucial to extend these findings beyond research or academic publications and to inform COPD patients, raising their awareness of how disease- and treatment-related characteristics can influence their self-management behaviors.

Across all three methods used in this study—the literature review, patient interviews, and questions posed to the expert panel—12 common factors associated with non-adherence to COPD self-management were identified. Although these factors were not determined through quantitative analysis, which makes it challenging to establish them as the primary causes of non-adherence, their consistent emergence across all methods indicates their importance. Most of the factors are related to personal, psychological, and functional characteristics, underscoring the necessity of addressing these areas in management strategies. Notably, four of the six factors pertaining to personal characteristics—excluding education level and religion—were highlighted by all three methods, indicating the key role of personal characteristics in non-adherence to COPD self-management. Since most personal characteristics (with the exception of smoking status) cannot be easily changed, patients who have COPD in conjunction with disadvantageous unmodifiable factors such as age, sex, and occupation may face a relatively high risk of non-adherence. Therefore, it is essential to focus on addressing modifiable factors like smoking status, social support, self-efficacy, and physical activity, as well as devising strategies to target these elements.

The primary limitation of this study was the difficulty of fully eliminating the influence of the researchers’ subjective perspectives when linking factor categories and factors. This risk inherently persists despite the employment of a thorough, systematic approach to identify and categorize the factors impacting non-adherence to COPD self-management. Additionally, the group of COPD experts consulted was confined to a single region, limiting the diversity of viewpoints.

This study involved the development of a conceptual framework based on eight identified factor categories and 53 specific factors that influence non-adherence to self-management among patients with COPD. By categorizing these factors, the study establishes a foundation for future research focused on interventions designed to improve COPD self-management.

Therefore, future research should employ this conceptual framework for quantitative analyses through pairwise comparisons of the factor categories and specific factors.