Chronic obstructive pulmonary disease (COPD) is an irreversible inflammatory respiratory condition that restricts the flow of air through the respiratory tract (Vestbo et al., 2013). According to the predictions of the World Health Organization (2018), COPD will be the third leading cause of death in Korea in 2030. The prevalence of COPD in Korea is 13.5%, and >20% for men and 6.1% for women older than 40 (Jeon & Oh, 2015). The prevalence of COPD in Korea is high compared with other countries. In North Asia, the prevalence of COPD among people age ≥40 years is 10.9% in Japan (Chan-Yeung, Aït-Khaled, White, Ip, & Tan, 2004), 7.7% in Hong Kong, 8.1% in China, and 9.5% in Taiwan (Lim et al., 2015). In the United States, the prevalence of COPD among individuals older than 18 is 6.1% (American Lung Association, 2013). Age, smoking, exposure to high-risk occupations, and air pollution could be the reasons for the higher prevalence of COPD in Asia (Chan-Yeung et al., 2004). In Korea, 19.7% of individuals smoke, which is a higher proportion than in other countries; smoking is a factor that likely underlies the high prevalence of COPD in Korea (Jung & Lee, 2011).
The natural progression of COPD involves gradual deterioration, but temporary stabilizations and acute exacerbations are also characteristic of this condition (Seemungal, Donaldson, Bhowmik, Jeffries, & Wedzicha, 2000). The purpose of treatment is to reduce symptoms, prevent deterioration, and delay disease progression (Park & Kang, 2017). The average rate of hospital readmission within 6 months after an acute exacerbation is 50% and the mortality rate within 1 year is 43%. Thus, COPD is a high-risk chronic disease that can be life-threatening for older adults with weak immune function (Jung & Lee, 2010).
Patients' perceptions of COPD are important determinants of their health care; these perceptions are influenced by feelings and thoughts regarding the disease. Better understanding of COPD leads to more active coping strategies, which improves patients' quality of life (Tiemensma, Gaab, Voofhaar, Asijee, & Kaptein, 2016). In particular, older adults with COPD can improve their quality of life by preventing disease, prolonging healthy periods, reducing periods of dysfunction, and participating in meaningful and independent activities through health promotion programs. Self-perceived health and health knowledge are necessary for older adults to cope with chronic disease (Kane & Arnold, 1985; Kim, Kim, & Sok, 2008).
COPD is irreversible. In addition to medical treatment, continuous self-management is necessary because lung function loss cannot be reversed. Older adults with more experience of disease tend to manage disease better than older adults with less experience (Fotoukian, Mohammadi Shahboulaghi, Fallahi Khoshknab, & Mohammadi, 2014). In contrast, other research has reported a negative impact on patients with COPD of hospitalization experience and aggravation of disease symptoms (Bang & Park, 2017). Although adequate patient self-management reduces hospitalizations and emergency department visits due to worsening illness by approximately 40% (Bourbeau, Nault, & Dang-Tan, 2004; Kang, Kim, & Hwang, 2008), self-management performance among Korean individuals with COPD has been found to be low (Kang et al., 2008). In addition, differential approaches according to gender are necessary, as the prevalence of COPD among men is more than twice than that among women in Korea (Jung & Lee, 2011). This higher prevalence could be due to the higher proportion of men who smoke (Kang et al., 1993); women were not allowed to smoke until the 1980s due to social norms (Kim & Cho, 2008).
In addition, due to differences in social needs between men and women, as dictated by the prevalent patriarchal culture in Korea, the perceived health-related quality of life of male patients with COPD is significantly lower than that of female patients (Kim & Kim, 2015). However, no previous research used narrative interviews, which are useful for analyzing the perceptions of patients with COPD regarding the disease and factors related to healthy behaviors. If productive group discussions could be effectively held to elicit the thoughts and perceptions of participants with the maximum use of group dynamics, valuable data could be obtained, which would contribute to understanding the phenomenon (Kim, Kim, Lee, & Lee, 2000). Therefore, the purpose of the current study was to qualitatively explore the perceptions and experiences of disease among Korean male older adults with COPD using narrative interviews.
A qualitative study of the perceptions and experiences of Korean older men with COPD was performed.
Participants were male older adults with COPD who were recruited from one academic hospital in Seoul, Korea. Inclusion criteria were: (a) age ≥65 and diagnosed with COPD by pulmonary function test (forced expiratory volume in 1 second/forced expiratory volume <0.7); (b) in the stabilization period of the disease and study participation recommended by a respiratory medicine specialist; (c) receiving appropriate medication and treatment as an outpatient for >6 months; (d) possessing sufficient auditory and language ability to communicate with others; (e) having an education level higher than primary school; and (f) able to understand the purpose of the study and method of interview to consciously agree to participate in the study and answer a follow-up telephone call. Exclusion criteria were inability to communicate with the group due to cognitive dysfunction or a mental disorder (e.g., dementia) and hypoxemia (oxygen saturation <92%) even in a stable state.
Six patients met the inclusion criteria and consented to participate in the study with the agreement of their physician. All participants were men ages 65 to 71, with a mean age of 67.5 years. The time from initial diagnosis of COPD ranged from 3 to 44 years, and the average disease period was 15.17 years. Four (85.4%) participants experienced acute exacerbation at least once. All participants had smoked in the past, and two smoked at the time of the research. Two participants had concomitant diseases, such as hypertension; the remaining four participants did not have other comorbidities.
The optimal number of participants for qualitative data collection varies according to the literature (Kim et al., 2000). The current qualitative interview included semi-structured questions and was considered complete when it was determined that no new data could be obtained (i.e., when the saturation state was reached). The interview was conducted in a quiet seminar room at the participating hospital.
The narrative interview took place after the introduction of the facilitator and participants. Participants were informed of ethical considerations and completed a simple questionnaire that collected demographic and COPD characteristics. The in-depth group interview was conducted using the structure of an introduction, transition, and key questions. These phases took place consecutively, and probe questions were used when necessary.
One researcher (K.K.) led the interview, while a research assistant (J.W.K., S.C.) audio recorded the interview using two separate devices to prevent data loss. The interviewer (K.K.) and another researcher (J.W.K.) noted important verbal content from participants' contributions. The understanding and interpretation of the interviewer and researcher were verified by participants at the end of the interview with reference to the notes. After the interview, the researchers discussed key information gained from the interview. If information appeared ambiguous, researchers confirmed the meaning by a follow-up telephone call to the participant(s).
To develop the questions for participants, the research team first generated draft questions after clarifying the research problem, which were then finalized through discussion with colleagues and qualitative analysis experts. The content was structured in terms of an introduction, transition, and key and finishing questions.
Prior to the start of the study, institutional review board approval was obtained. Before the interview, researchers informed participants about the research purpose, their right to withdraw, and issues of confidentiality and anonymity. In addition, written consent was obtained from all participants.
Interview data were processed using content analysis via the program NVivo® 12.0. After transcribing the recording, the transcription was repeatedly read and segmented, which involved identifying sentences in which the meaning and main points of the context were well understood. The process of segmentation was conducted through peer consultation to increase reliability. In the next step, subject-related words were collected based on the segmented data, and the sentences were analyzed by open coding. This process also involved reaching consensus in peer consultation. In the final step, researchers conducted coding classification to generate categories by searching for associations between themes. Furthermore, the triangular verification method was used to increase reliability.
Content analysis revealed that the perceptions and experiences of older adults with COPD were divided into two main categories and 11 sub-themes. Specifically, the two categories were Process of Disease Adaptation and Barriers and Enablers Regarding Healthy Behaviors After Disease Adaptation.
In Process of Disease Adaptation, social stigma, blaming others and the environment, stress to bear alone, and adaptation and management were identified as relevant themes. Four themes, namely adapting to symptoms, external environmental factors, alternative treatments, and insufficient resources, emerged as barriers to healthy behaviors after disease adaptation. In addition, three themes, namely past symptom experience, personal volition, and advice from health professionals, were identified as enablers of healthy behaviors. The details of each category are shown in Figure 1, and sample quotes are presented.
Disease experiences of Korean older men with chronic obstructive pulmonary disease.
NVivo analysis yielded a total of 117 queries used in the course of disease adaptation (Table 1). Words that frequently occurred were obstructive (n = 54), cigarette (n = 30), lung disease (n = 23), and respiratory (n = 19).
Results of Narrative Interview Coding
Process of Disease Adaptation
Social Stigma. Participants perceived COPD as a social stigma. They lacked understanding of the pathology of the disease and expressed that their social activities were limited because COPD was confused with lung disease and often misrepresented as tuberculosis by family, friends, and other individuals with whom participants engaged socially. Unlike the current well-informed perspectives of cardiovascular diseases among older adults, lack of understanding of COPD leads to associating it with the past social stigma of tuberculosis, which was a prevalent cause of death among prior Korean generations. Moreover, there were cases in which the disease was diagnosed along with other diseases, such as asthma or mild respiratory disease, or the patient was not informed about the disease.
Lung disease is what pulmonary tuberculosis used to be called in the day…. This tuberculosis is a really… embarrassing…thing. If somebody has lung disease, you cannot even hang out. I'm really embarrassed…. (Participant 1)
If we have lung disease, people do not eat with us, and walk away. Everything is far away. And people try to avoid conversations as well, and they all stay away. I never said I had lung disease. (Participant 2)
Blaming Others and the Environment. Participants blamed decades-long jobs and the associated environments as the cause of COPD. They believed that the disease was caused by long-term or even two-time exposure to pollutants such as bad air, wax, lime, cement, or humidifier disinfectant.
My job is cleaning, so I think the air is waxy and it's contaminated…. There is no ventilation in the underground saunas, and because I was cleaning the water, I got the disease. (Participant 5)
My kids got two bags of humidifier disinfectant for free on the road. I put it in the humidifier overnight. I only used it twice…. But now, after a while, a lot of people died from the humidifier disinfectant. This has had an adverse effect on me. (Participant 6)
First of all, I smoked and worked in a car [private taxi] for 50 years. I think I did everything wrong. (Participant 2)
Stress to Bear Alone. Most participants worried about their breathing suddenly stopping due to COPD as they were the primary breadwinners in their homes, which in turn led to a cycle of stress and difficulty in breathing. Participants lagged in everyday life and were constantly limited by the disease. They thought that they should be able to endure this stressful situation alone and adjust to it.
When my son goes to work out, I hear a wheezing sound because I have trouble breathing. So, when I meet my friends or parents, I always feel pain…. When breathing is really difficult, I inhale the MDI [metered dose inhaler] gently in secret, not in front of others…. Stress at the moment? I feel most sick when I get stressed. In that moment. Because when I get stressed, my breathing suddenly goes up. (Participant 4)
Now I think I will not be able to survive. So, the most important thing seems to be finding peace in your mind. (Participant 2)
Adaptation and Management. Participants with negative perceptions of the disease tried to compare it to less serious diseases and be aware of the positive aspects. They were adapting to a chronic disease that could not be cured. In addition to receiving counseling from health professionals, they acquired and applied various methods for relieving physical symptoms and tried to accept the disease and control its symptoms in daily life.
I have never thought of lung disease until now. Just a respiratory illness, this is not a complete recovery. It's the same as with hypertension and diabetes. (Participant 1)
When I was growing up, lung disease was the worst thing, aggravated by smoking and bad air, starting with the bad air. When I got off the subway, I would just spit out my sputum and breathe a little…. When I go somewhere, I take the subway, and when I get back, I mostly take a taxi because of the breathing problems. (Participant 4)
I am an old man in pain when I'm standing, and I'm struggling to take a breath…. And when I climb up the stairs, it's hard to breathe. Oh, now when I think I will have to go up the stairs, I have a little spray [MDI] once or twice and then I breathe. (Participant 3)
Experience of Disease
Barriers to Healthy Behaviors. Adapting to Symptoms. Participants managed their long-term disease and when their symptoms did not worsen or improve with medication, they adjusted by increasing unhealthy behaviors or stopping healthy behaviors. The most difficult healthy behaviors were ceasing smoking and drinking alcohol. When there was no discomfort or difficulty in breathing, participants engaged in unhealthy behaviors, such as stopping or reducing medication.
I went up two or three floors and it was not easy for me to breathe. I had been going for about 6 months, and I felt like I was okay, and I drank some alcohol. After about a year of drinking, I started to breathe with difficulty. (Participant 1)
Now I take some medication in this hospital. Despite having a monthly doctor appointment, once every 2 months…if the results are good, once every 3 months. (Participant 3)
I have mild symptoms, so I did not take any medication for 20 days in a place with good air. Unlike with blood pressure pills, I tend to neglect this respiratory medicine. (Participant 6)
External Environmental Factors. Participants knew that smoking was an important factor in disease management, but they blamed various external environmental factors for their difficulty in quitting smoking. Participants mentioned stress reduction and personal events to justify not stopping smoking, but recognized smoking as a potentially negative health behavior that they should stop at some point. In addition, those living in metropolitan areas tried to avoid the pollution caused by public transportation, considering it to be the source of their symptom deterioration, but as long as they lived in a large city, they thought there was no alternative.
I'm told that this is medically bad, but people under stress like cigarettes. It's great. A cigarette just makes me feel like I'm going up and down. That's my favorite. (Participant 4)
I take a bus to go to nearby places, not the subway, because of the bad air. When I'm in a hurry, I struggle with shortness of breath and cough…. It is very hard not to use the subway living here in Seoul. (Participant 4)
Alternative Treatments. Participants did not have any apparent side effects or discomfort caused by medication they were taking, but they were constantly looking for other ways to reduce symptoms.
I saw it on the internet or a book…. I stopped my breathing difficulties with blocking one nostril and breathing through it. (Participant 6)
You know when I am a little short of breath…I take a deep breath, and then I feel like I am comfortable. (Participant 2)
So, I'm buying a disposable oxygen ventilator. There's a huge difference between the respiratory nebulizer in the hospital and the one I will buy. (Participant 3)
Insufficient Resources. Individuals experiencing a long-term disease need various resources to improve their healthy behaviors, and participants mentioned lack of resources as a barrier to adopting such behaviors. Participants had not used breathing rehabilitation therapy, self-help groups, or social support and had undergone only short interviews with a physician and medication therapist. Nonpharmacological interventions are useful to manage symptoms efficiently, and participants regretted not using such interventions because of lack of resources.
It is the first time I have been in a hospital in three or four decades and I have been having this kind of conversation with patients with the same disease. So, I hope to have good information and opportunities in the future, even if I have to visit the hospital a few times a year. (Participant 5)
I think it is good if the hospital introduces me to something that I can do every day. If I learn about breathing exercises, I will do them often, even if it is not every day. It's hard to get to a place with good air in this environment. I can't live by the sea or in the mountains. (Participant 4)
Enablers of Healthy Behaviors. Past Symptom Experience. Participants engaged in healthy behaviors to prevent symptoms from worsening based on past experiences of acute exacerbations or difficulty in breathing. Avoidance of poor-air environments, strenuous exercise, and stress; fatigue management; nutritional management; and personalized drug scheduling with on-demand medication were mentioned.
When I work until I am tired, I'm not well. I feel fatigued and stressed. I have to eat well. (Participant 1)
I do this one [inhaler] twice a day, and that one [second inhaler] once a day…. It is good to do it before being short of breath, then I have no breathing difficulties anymore. (Participant 3)
Personal Volition. Although the advice of health professionals is important for patients who have had a disease for a long time, participants noted that it was the patients themselves who followed the advice and engaged in healthy behaviors of their own will. To manage their symptoms, it was best when patients themselves identified healthy behaviors and methods that best suited them.
Even if the professor says, “Do this for yourself,” do I do it? I don't think anyone who's been living 60–70 years and looking after themselves would listen to that. I have to do it myself. No matter how many people think that cigarettes are worthless, it is hard to stop until I feel like it. (Participant 5)
For the first week, the third floor is also difficult. But after a while, I can climb to the sixth or seventh floor. But if you stop exercising, you won't be able to go up the stairs next time. (Participant 3)
Advice From Health Professionals. Participants showed confidence in the healthy behavior advice provided by physicians/professors of the university hospital and in the prescribed medication. Participants were sympathetic to the advice on smoking cessation and understood the need to stop smoking due to their COPD symptoms. In addition, participants experienced symptom relief when following their physician's advice that was provided through regular visits; this advice promoted engagement in healthy behaviors, although there were differences among participants in healthy behaviors, such as smoking cessation and reduction.
The doctor forced me to quit smoking. It was quite difficult to stop…. From then on, it got much better. The color of my skin has improved, and the taste of food has improved. (Participant 5)
I have been taking medicine steadily…and I've been doing some exercise. Since then, I have never felt breathless or short of breath. (Participant 6)
The current study identified the disease perceptions and experiences of Korean male older adults with COPD. During the interviews, the first theme that emerged from participants was the stigma related to COPD. Generally, stigma is socially constructed, and individuals who are stigmatized experience various kinds of social rejection (Berger, Kapella, & Larson, 2011; Halding, Heggdal, & Wahl, 2011). In the current study, participants considered COPD a lung disease akin to pulmonary tuberculosis. Previous studies that focused on the stigma of COPD found that patients, their relatives, and others blame smoking as the primary cause of COPD. Patients with COPD in the current study knew that smoking is the major cause of COPD and that they should stop smoking. In addition, public health campaigns have focused on discouraging smoking by increasing the stigma associated with it, which can cause unintended negative effects on stigmatized individuals (Halding et al., 2011). Even if the reasons for stigmatizing patients with COPD vary, stigma can be harmful to their identity and have a negative impact on their health (Halding et al., 2011; Strang et al., 2014). In Korea, the stigma related to COPD may be caused by lack of knowledge regarding this condition. Therefore, providing adequate information about COPD to the public could reduce the stigma associated with this disease.
Participants realized smoking was the main cause of their disease, but they also assigned blame to other factors. This part of the process served as disease adaptation as well as a barrier to healthy behaviors. This finding is consistent with previous research that found smokers with COPD tend to focus on other causes of disease, such as family history, exposure to pollution, or age (Halding et al., 2011), suggesting that patients with COPD use coping strategies (Strang et al., 2014). Smoking cessation is one of the most effective measures by which to prevent COPD and is thus a key factor in counseling patients with COPD (Vestbo et al., 2013). However, participants stated it was difficult for them to quit and identified external factors as the reason for not quitting. Some individuals do not realize that smoking exacerbates COPD (O'Neill, 2002) or find that quitting does not improve their health (Halding et al., 2011). Paradoxically, frequency of smoking can increase when experiencing difficulties due to COPD (The Tobacco Use and Dependence Clinical Practice Guideline Panel, Staff, and Consortium Representatives, 2000).
Participants experienced stress that they believed they had to bear on their own. In the current study, all participants were men and were the main breadwinners in their family. Consequently, they experienced stress due to the illness limiting their social life and family role as a father. In particular, the decline in mobility associated with COPD often reduces autonomy, activity, and productivity, as well as social contact and the ability to fulfill one's social roles (Park & Kang, 2017).
Confucianism emphasizes the suppression of expression of feelings by men. The philosophy is consistent with engaging in self-management, perseverance, and indirect approaches to solve problems (Park, Stotts, Douglas, Donesky-Cuenco, & Carrieri-Kohlman, 2014). This culture may discourage men with COPD from expressing their stress and problems to their family or relatives. According to Chang, Dai, Chien, and Chan (2016), in Taiwan, which also has a culture informed by Confucianism, individuals with COPD believe that children caring for their parents is an expression of respect. However, parents with COPD worried that their illness would burden their children.
Participants expressed that having insufficient resources was a barrier to healthy behaviors. These barriers included negative social support from family and social networks, and negative factors related to disease management (Sheridan et al., 2011). Individuals with COPD in the United Kingdom expressed the importance of participating in daily activity, including walking, household maintenance, driving, and maintaining social relationships (Williams, Bruton, Ellis-Hill, & McPherson, 2007). Patients with higher education levels and incomes are more likely to have access to the material resources and information they need for treatment, use more positive coping strategies, and maintain good interpersonal relationships (Park & Kang, 2017). Economic difficulties, confusion, language barriers, and low health literacy can hinder self-management, health care, and coping (Park & Kang, 2017). It is essential for health care providers to offer as much information and support as possible to patients with COPD, from the moment they are first diagnosed. Unlike in Western cultures, Korean individuals experience difficulties expressing their disease experience to others, including their feelings, physical status, and stressors (Park et al., 2014). Therefore, health care providers should carefully assess these patients to promote their health status and the ability of the individual to perform self-management.
Participants tried to regard their illness as non-serious and adapt to it in their daily lives. Their ongoing struggle with COPD notwithstanding, not all patients were aware that their health would deteriorate over time, as some symptoms are due to transient and immediate causes, such as worsening self-care or environmental changes (Giacomini, DeJean, Simeonov, & Smith, 2012). Self-management efforts to improve or maintain function can improve health-related quality of life in individuals with chronic, incurable conditions (Kim & Lee, 2017; Kim & Park, 2016). Participants were aware that self-management was important; however, they applied their own health management methods in addition to pharmacotherapy. Previous studies have found that self-care of patients with COPD is poor (Kang et al., 2008), with medication adherence being the factor with poorest compliance. Adequate treatment that includes self-management is crucial for reducing the severity of COPD and improving the quality of life of those with the condition (Halding et al., 2011). Self-management strategies include exercise, breathing techniques, auxiliary equipment, and controlling or avoiding harmful environments. It is necessary to develop active and customized nursing interventions to promote self-management, which should consider subjective symptom experience and self-management ability and focus on improving quality of life by reducing the occurrence of symptoms (Kang et al., 2008).
Healthy behaviors of patients with COPD are promoted by past experiences of symptoms, advice from health professionals, and willingness to implement such advice (Fotoukian et al., 2014). An older patient with COPD is typically an experienced individual who can find the best solution to control his or her life and illness and help others by reflecting on past events, gaining knowledge-based experience, and evaluating the results (Fotoukian et al., 2014). Although internal perceptions are difficult to change, they should be addressed to reduce the negative effects of stigma associated with COPD (Halding et al., 2011). In Korea, home-based pulmonary rehabilitation programs are available to patients with COPD. These programs include exercise, education, and psychosocial interventions. The benefits of home-based interventions are that the content of the intervention can be adjusted according to the patient's physical condition, so that the amount of exercise can be controlled and the frequency of inconvenient hospital visits can be reduced (Ahn, Choi, & Kim, 2016; Jung & Kim, 2006; Song, 2015). It is necessary to develop personalized interventions that reflect the individual's knowledge, experience, and needs.
In the current study, advice from health professionals was an important factor in participants' engagement in healthy behaviors. Health professionals' attitudes and behaviors can have a significant impact on patients' attitudes toward disease and disease management. The attitude of the physician toward chronic condition management may be more important than the physician's knowledge of the disease (Sheridan et al., 2011). A positive relationship between patients and health workers is essential, especially because this patient group generally exhibits low self-esteem, depression, and guilt over what they consider to be self-defeating behaviors (Roberts, Ghiassi, & Partridge, 2008). However, previous studies have found that clinicians tend to focus on crisis management rather than devote their time to engaging in difficult conversations with patients regarding the condition of the latter. Health professionals should provide advice about the disease and consider patients' individual situations (Halding et al., 2011; Robinson, 2005; Vestbo et al., 2013).
The current study had some limitations. First, the variety of opinions elicited from participants may have been limited for the purpose of the study. In addition, analyzing the experience of patients in a single area limits the generalizability of the results. Nevertheless, the study adds to the current literature in that it used narrative interviews to elucidate factors that affect health-related behaviors of patients with COPD, with reference to their perceptions and experiences of the disease.
Social stigma, blaming others and the environment, stress to bear alone, and adaptation and management emerged as themes relevant to older men with COPD as they adapted to the condition. Obstacles to healthy behaviors were adapting to symptoms, external environmental factors, alternative treatments, and insufficient resources. Past symptom experience, personal volition, and advice from health professionals were identified as enablers of healthy behaviors. Older adults with COPD should have sufficient resources and social support from families, social networks, and health professionals to promote adaptation to their disease. In particular, interventions for older patients with COPD should be based on the knowledge and understanding of the individual patient's disease experience and needs. The current study may contribute to broadening the understanding of disease adaptation processes in various cultural environments for gerontological nurses who care for older adults with COPD. In addition, to improve the quality of nursing care in the future, it is necessary to expand research into the various cultural environments of older adults and their process of adaptation to chronic disease.
- Ahn, M. H., Choi, J. Y. & Kim, Y. H. (2016). A systematic review of home based pulmonary rehabilitation in COPD patients: Randomized controlled trials. Korean Journal of Rehabilitation Nursing, 19(2), 82–99 doi:10.7587/kjrehn.2016.82 [CrossRef]
- American Lung Association. (2013). COPD prevalence rates and counts by state and gender. Retrieved from https://www.lung.org/assets/documents/research/copd-2013-prevalence-and.pdf
- Bang, Y. Y. & Park, H. (2017). Relationship of knowledge about disease, illness attitude, and quality of life for patients with chronic obstructive pulmonary disease (COPD). Journal of the Korean Contents Association, 17(11), 410–422.
- Berger, B. E., Kapella, M. C. & Larson, J. L. (2011). The experience of stigma in chronic obstructive pulmonary disease. Western Journal of Nursing Research, 33(7), 916–932 doi:10.1177/0193945910384602 [CrossRef] PMID:20940446
- Bourbeau, J., Nault, D. & Dang-Tan, T. (2004). Self-management and behaviour modification in COPD. Patient Education and Counseling, 52(3), 271–277 doi:10.1016/S0738-3991(03)00102-2 [CrossRef] PMID:14998597
- Chan-Yeung, M., Aït-Khaled, N., White, N., Ip, M. S. & Tan, W. C. (2004). The burden and impact of COPD in Asia and Africa. The International Journal of Tuberculosis and Lung Disease, 8(1), 2–14 PMID:14974740
- Chang, Y. Y., Dai, Y. T., Chien, N. H. & Chan, H. Y. (2016). The lived experiences of people with chronic obstructive pulmonary disease: A phenomenological study. Journal of Nursing Scholarship, 48(5), 466–471 doi:10.1111/jnu.12230 [CrossRef] PMID:27355698
- Fotoukian, Z., Mohammadi Shahboulaghi, F., Fallahi Khoshknab, M. & Mohammadi, E. (2014). Barriers to and factors facilitating empowerment in elderly with COPD. Medical Journal of the Islamic Republic of Iran, 28(155), 155 PMID:25695013
- Giacomini, M., DeJean, D., Simeonov, D. & Smith, A. (2012). Experiences of living and dying with COPD: A systematic review and synthesis of the qualitative empirical literature. Ontario Health Technology Assessment Series, 12(13), 1–47 PMID:23074423
- Halding, A. G., Heggdal, K. & Wahl, A. (2011). Experiences of self-blame and stigmatisation for self-infliction among individuals living with COPD. Scandinavian Journal of Caring Sciences, 25(1), 100–107 doi:10.1111/j.1471-6712.2010.00796.x [CrossRef] PMID:20534028
- Jeon, C. M. & Oh, K. W. (2015). Prevalence of chronic obstructive pulmonary disease among adults over 40 years old in Korea, 2009–2013. Public Weekly Report, 8(15), 334–336.
- Jung, J. H. & Kim, J. Y. (2006). The effects of self-efficacy promoting pulmonary rehabilitation program in out-patients with chronic obstructive pulmonary disease. Tuberculosis and Respiratory Diseases, 61(6), 533–546 doi:10.4046/trd.2006.61.6.533 [CrossRef]
- Jung, Y. M. & Lee, H. Y. (2010). Risk factors of chronic obstructive pulmonary disease in Korean elderly. Journal of Korean Living Environment System, 17(2), 214–223.
- Jung, Y. M. & Lee, H. Y. (2011). Chronic obstructive pulmonary disease in Korea: Prevalence, risk factors, and quality of life. Journal of Korean Academy of Nursing, 41(2), 149–156 doi:10.4040/jkan.2011.41.2.149 [CrossRef] PMID:21551985
- Kane, R. L. & Arnold, S. B. (1985). Prevention and the elderly: Risk factors. Health Service Research, 19, 945–955.
- Kang, G. J., Kim, M. H. & Hwang, S. K. (2008). Self-care, symptom experience, and health-related quality of life by COPD severity. Korean Journal of Adult Nursing, 20(1), 163–175.
- Kang, S. W., Han, K. M., Kim, K. Y., Choi, C. H., Bae, C. Y. & Shin, D. H. (1993). A study of geriatric inpatients. Korean Journal of Family Medicine, 14(11), 715–724.
- Kim, H. J. & Lee, M. K. (2017). The relationship between illness perception and health behavior among patients with tuberculosis: Mediating effects of self-efficacy and family support. Korean Journal of Adult Nursing, 29(6), 626–636 doi:10.7475/kjan.2017.29.6.626 [CrossRef]
- Kim, J. & Kim, K. (2015). Gender differences in health-related quality of life of Korean patients with chronic obstructive lung disease. Public Health Nursing (Boston, Mass.), 32(3), 191–200 doi:10.1111/phn.12129 [CrossRef] PMID:24852139
- Kim, K. B., Kim, H. A. & Sok, S. R. (2008). A study on health perception, health knowledge, and health promoting behavior in the elderly. Journal of East-West Nursing Research, 14(1), 56–67.
- Kim, N. H. & Park, J. H. (2016). Factors influencing health-related quality of life of patients with chronic obstructive pulmonary disease. Journal of Muscle and Joint Health, 23(3), 159–168 doi:10.5953/JMJH.2016.23.3.159 [CrossRef]
- Kim, S. J., Kim, H. J., Lee, K. J. & Lee, S. O. (2000). Focus group method. Seoul, Korea: Hyunmoon.
- Kim, Y. S. & Cho, H. S. (2008). Smoking behavior and related factors of female smokers from public health center in Incheon. Korean Society for Health Education and Promotion, 9, 125–138.
- Lim, S., Lam, D. C., Muttalif, A. R., Yunus, F., Wongtim, S., Lan, T. T. & de Guia, T. (2015). Impact of chronic obstructive pulmonary disease (COPD) in the Asia-Pacific region: The EPIC Asia population-based survey. Asia Pacific Family Medicine, 14(1), 4 doi:10.1186/s12930-015-0020-9 [CrossRef] PMID:25937817
- O'Neill, E. S. (2002). Illness representations and coping of women with chronic obstructive pulmonary disease: A pilot study. Heart & Lung, 31(4), 295–302 doi:10.1067/mhl.2002.123712 [CrossRef] PMID:12122393
- Park, S. K., Stotts, N. A., Douglas, M. K., Donesky-Cuenco, D. & Carrieri-Kohlman, V. (2014). Dyspnea coping strategies in Korean immigrants with asthma or chronic obstructive pulmonary disease. Journal of Transcultural Nursing, 25(1), 60–69 doi:10.1177/1043659612472709 [CrossRef] PMID:24346615
- Park, S. M. & Kang, Y. H. (2017). Symptom experience, self-efficacy, depression, and medication adherence in patients with chronic obstructive pulmonary disease. Journal of Korean Clinical Nursing Research, 23(2), 170–178.
- Roberts, N. J., Ghiassi, R. & Partridge, M. R. (2008). Health literacy in COPD. International Journal of COPD, 3(4), 499–507 PMID:19281068
- Robinson, T. (2005). Living with severe hypoxic COPD: The patients' experience. Nursing Times, 101(7), 38–42 PMID:15759524
- Seemungal, T. A., Donaldson, G. C., Bhowmik, A., Jeffries, D. J. & Wedzicha, J. A. (2000). Time course and recovery of exacerbations in patients with chronic obstructive pulmonary disease. American Journal of Respiratory and Critical Care Medicine, 161(5), 1608–1613 doi:10.1164/ajrccm.161.5.9908022 [CrossRef] PMID:10806163
- Sheridan, N., Kenealy, T., Salmon, E., Rea, H., Raphael, D. & Schmidt-Busby, J. (2011). Helplessness, self blame and faith may impact on self management in COPD: A qualitative study. Primary Care Respiratory Journal, 20(3), 307–314, 1, 314. doi:10.4104/pcrj.2011.00035 [CrossRef] PMID:21509413
- Song, H. Y. (2015). Developing a home-based self-management support intervention for pulmonary rehabilitation in patients with chronic obstructive pulmonary disease. Korean Journal of Rehabilitation Nursing, 18(2), 75–87 doi:10.7587/kjrehn.2015.75 [CrossRef]
- Strang, S., Farrell, M., Larsson, L. O., Sjöstrand, C., Gunnarsson, A., Ekberg-Jansson, A. & Strang, P. (2014). Experience of guilt and strategies for coping with guilt in patients with severe COPD: A qualitative interview study. Journal of Palliative Care, 30(2), 108–115 doi:10.1177/082585971403000206 [CrossRef] PMID:25058988
- Tiemensma, J., Gaab, E., Voorhaar, M., Asijee, G. & Kaptein, A. A. (2016). Illness perceptions and coping determine quality of life in COPD patients. International Journal of COPD, 11, 2001–2007 doi:10.2147/COPD.S109227 [CrossRef] PMID:27601893
- The Tobacco Use and Dependence Clinical Practice Guideline Panel, Staff, and Consortium Representatives. (2000). A clinical practice guideline for treating tobacco use and dependence. Journal of the American Medical Association, 283(24), 3244–3254 doi:10.1001/jama.283.24.3244 [CrossRef] PMID:10866874
- Vestbo, J., Hurd, S. S., Agustí, A. G., Jones, P. W., Vogelmeier, C., Anzueto, A. & Rodriguez-Roisin, R. (2013). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. American Journal of Respiratory and Critical Care Medicine, 187(4), 347–365 doi:10.1164/rccm.201204-0596PP [CrossRef] PMID:22878278
- Williams, V., Bruton, A., Ellis-Hill, C. & McPherson, K. (2007). What really matters to patients living with chronic obstructive pulmonary disease? An exploratory study. Chronic Respiratory Disease, 4(2), 77–85 doi:10.1177/1479972307078482 [CrossRef] PMID:17621574
- World Health Organization. (2018). Chronic obstructive pulmonary disease (COPD). Retrieved from http://www.who.int/respiratory/copd/en/
Results of Narrative Interview Coding
| Enablers of health behaviors
| Awareness about disease
| Barriers to health behavior
| Symptoms of disease
|Frequent words during interviewsa
| Lung disease
| In hospital
| First time
| Air (atmosphere)
| Test (health check-up)