UNDERSTANDING THE SELF-MANAGEMENT PRACTICES IN LEBANESE PATIENTS DIAGNOSED WITH COPD: BARRIERS AND FACILITATORS FROM THE PERSPECTIVES OF PATIENTS AND PHYSICIANS - A QUALITATIVE STUDY

Abstract

Background:
Chronic Obstructive Pulmonary Disease (COPD) is a global health issue with significant prevalence and mortality. The global prevalence is estimated at 10.3% among adults aged 30 to 79 years, affecting approximately 391.9 million individuals worldwide (Adeloye et al., 2022). In the Middle East and North Africa (MENA) region, the age-standardised point prevalence is 2,333.9 per 100,000 population, reflecting a 30.6% increase since 1990 (Feizi et al., 2022).

In 2021, COPD was ranked as the fourth leading cause of death globally, responsible for around 3.5 million deaths—approximately 5% of all deaths (World Health Organization, 2024). Nearly 90% of COPD-related deaths among individuals under the age of 70 occur in low- and middle-income countries, highlighting the urgent need for targeted interventions in these settings.

Given the increasing burden of COPD both globally and in the MENA region, effective interventions, such as self-management (SM), have become critical for improving patient outcomes, particularly for enhancing health-related quality of life (HRQoL) and reducing the likelihood of respiratory-related hospital admissions (Schrijver et al., 2022).

The study’s initial scoping review mapped the existing literature on SM for COPD in Arab and Middle Eastern countries. It revealed a limited number of studies addressing SM broadly, with no studies specifically investigating SM in Lebanon. Particularly, there is a lack of understanding regarding the practices patients undertake to manage the disease and the barriers and facilitators from the perspectives of both patients and pulmonary physicians. In this context, exploring how patients manage their COPD, as well as the barriers and facilitators to SM from the perspectives of both patients and physicians, is essential for informing culturally relevant self-management programs.

Aim:
This study aims to address a critical gap in the literature by exploring current self-management (SM) practices for COPD, with the goal of better understanding the scope and nature of SM within the local context. Additionally, the study seeks to identify the barriers and facilitators to SM from the perspectives of both patients and physicians. By identifying cultural and systemic factors that influence SM, the study aims to inform the development of context-sensitive and culturally appropriate SM interventions.

Methods:
A qualitative study was conducted using in-depth semi-structured interviews to explore self-management (SM) practices for COPD in Lebanon. Ten patients diagnosed with COPD and eleven physicians involved in pulmonary care were recruited through purposive sampling. Face-to-face interviews were conducted, focusing on how patients manage their condition and the perceived barriers and facilitators to SM from both patient and physician perspectives. Data were analysed using reflective thematic analysis (TA), guided by the revised Self- and Family Management Framework (Grey et al., 2015), to identify key patterns and themes related to SM practices as well as related barriers and facilitators.

Findings:
The main themes are closely aligned with the adopted Self- and Family Management Framework. Patients primarily manage their illness by learning about the disease, recognising and monitoring symptoms, and managing medications. However, engagement in health promotion activities—such as physical activity and smoking cessation—was limited. Notably, patients may engage in unaffavourable practices such as shifting to non-traditional smoking or taking antibiotics without the guidance of treating physicians. To support self-management, patients utilised various resources, including healthcare (primarily physicians and pharmacists), social (mainly family and close acquaintances), and spiritual resources (providing emotional comfort). This process led to patients gradually integrating the disease into their daily lives, particularly through medication adherence and adjustments to physical activity routines.

From the patients' perspective, several facilitators supported their engagement with self-management (SM). These included personal and lifestyle factors, such as knowledge about the harmful effects of smoking, the signs and symptoms of exacerbations, fear and anxiety related to death, enjoyment of walking, motivation to quit smoking, and prior experiences with COPD. Health status factors, including the severity of COPD and the perception of reduced cravings, also played a role. Additionally, available resources—such as access to health insurance and medical equipment—were important. Environmental factors, including supportive home settings and environments that fostered physical activity (PA), further facilitated SM. Healthcare system factors, such as easy access to care and specialised programs, as well as a trusting relationship between patients and physicians, were also crucial.

Conversely, patients reported several barriers to self-management (SM), including personal lifestyle factors such as lack of knowledge about the importance of physical activity in COPD, misconceptions about non-traditional smoking methods, dependence on smoking for stress relief, lack of motivation to quit smoking, previous smoking habits, and disruption of daily routines. Health status-related barriers included the severity of the condition, co-morbidities, and cravings and withdrawal symptoms. Environmental factors such as sociopolitical instability in the country, unsupportive home environments, and community-level challenges—such as a lack of favourable spaces for physical activity and a community that encourages smoking behaviour—also hindered SM.

From the physician's perspective, facilitators for self-management (SM) include patients' internal motivation to quit smoking, the severity of COPD, available resources such as educational materials and the type of inhaler device, and the collaborative approach between physicians and patients, as well as informal relationships between patients and physicians.

On the other hand, several barriers to SM were identified, including personal and lifestyle factors such as a lack of general awareness of COPD, misconceptions about smoking cessation and the importance of physical activity in COPD, lack of motivation to quit smoking or engage in physical activity, and previously adopted sedentary behaviours. Health status-related barriers include the severity of the condition, co-morbidities, nicotine dependence, and delayed treatment effects. Resource-related challenges include the high cost of treatment, lack of coverage by third-party payers, a challenging reimbursement process, shortage of skilled personnel, limited time resources for both patients and physicians, and the complexity of the devices used for treatment. Community-related factors, such as the social norm of smoking in Lebanon and the sociopolitical environment, also impact SM. Furthermore, healthcare system challenges, including limited access to care, the lack of a multidisciplinary approach, and unregulated access to antibiotics, were identified as significant barriers.

Discussion and Conclusion:
This study emphasises that while patients actively engage in managing their COPD, their focus is primarily on medication adherence and exacerbation control. However, unfavourable behaviours, such as switching to non-traditional smoking methods and the use of antibiotics without the guidance of physicians, were also noted. These findings underscore the need for self-management (SM) interventions that prioritise preventive behaviours, particularly physical activity (PA) and smoking cessation and address unfavourable practices.

The process of SM is multifaceted, with both patients and physicians identifying several factors that influence SM, including personal lifestyle patterns, health status, available resources, environmental influences, and healthcare system factors. These findings highlight that the barriers and facilitators of SM are deeply embedded in the specific context of the patients, suggesting a need for tailored SM interventions. Such interventions should be adapted to the cultural context of the Lebanese population, addressing prevalent misconceptions and beliefs that shape SM behaviours, while also leveraging identified facilitators to enhance engagement in preventive care.

Date of Award	2026
Original language	English
Awarding Institution	University of Dundee
Supervisor	Tim Croudace (Supervisor), Pam Ramsay (Supervisor) & Samar Noureddine (Supervisor)