Knowledge,attitude,and practice toward disease prevention among a high-risk population for chronic obstructive pulmonary disease: Across-sectional study

Lulu Zhao ,Qinghua Zhao

a Department of Nursing,The First Affiliated Hospital of Chongqing Medical University,Chongqing,China

b Department of Nursing,The People’s Hospital of Dazu,Chongqing,China

Keywords: Chronic obstructive pulmonary disease Risk Knowledge Attitudes Practice

ABSTRACT Objective:This study aimed to describe the current situation of knowledge,attitude,and practice (KAP)of chronic obstructive pulmonary disease (COPD) prevention among a high-risk population for COPD.Methods:A cross-sectional survey was conducted.A total of 241 participants at risk of COPD were selected who visited the respiratory outpatient department of a Class A tertiary hospital in Chongqing,China from January to December 2021.A self-developed COPD prevention KAP assessment was used for evaluation which included knowledge (21 items),attitude (9 items),and practice (9 items) three dimension,39 items.Results:The average overall KAP score was 68.29 ± 12.91,with scores for the knowledge,attitude,and practice dimension was 68.75±18.07,71.13±15.09 and 65.00±20.93,respectively.Among the people at risk of COPD,76.8%experienced a moderate level of KAP toward COPD prevention,while 22.0%were at a poor level.Significant differences in the KAP scores were based on gender,educational level,occupation,type of medical insurance,smoking,and passive smoking status (P ＜0.05).The male COPD high-risk group has better KAP toward COPD prevention than the female group (P ＜0.05).The knowledge and attitude of COPD prevention present worse in people with a high risk of COPD aged 70 or above,primary school and below educational level,and farmers (P ＜0.05).Smoking and passive smoking groups have higher recognition of the knowledge but the lower practice of COPD prevention (P ＜0.05).Conclusion:The participants with a high risk of COPD had a moderate level of KAP for COPD prevention,in which the understanding and action on vaccination and lung function test was weak,but an active attitude for health.It is necessary to implement tailored health education interventions to their characteristics to reduce the incidence and development of COPD.

What is known?

·Chronic obstructive pulmonary disease(COPD)is one of the top three causes of death worldwide,with high prevalence,disability rates,and serious social and economic burdens.

·The primary prevention (causal prophylaxis) is the key to reducing the incidence of COPD.Early identification of individuals with a high-risk of COPD and targeting them for preventive interventions might prove important in COPD prevention.

·Previous studies have focused on exploring different COPD prevention or management strategies.Few data are available in the literature highlighting the knowledge,attitude,and practice levels regarding COPD prevention among high-risk populations for COPD.

What is new?

·This study demonstrated that people with a high-risk of COPD had moderate knowledge,attitude,and practice toward COPD prevention.The preventative behavior was the lowest among the three dimensions.

·The weakness of COPD prevention in knowledge,attitude,and practice (KAP) is that they generally lack the action of COPD prevention,such as vaccination and lung function tests,and with an insufficient understanding of risk factors for early-life events.

·The KAP scores regarding COPD prevention in high-risk COPD were determined by demographic characteristics,especially in age,occupation,educational level,smoking,and passive smoking groups.

1.Introduction

Chronic obstructive pulmonary disease(COPD)is one of the top three causes of death worldwide,resulting in huge economic,social,and healthcare burdens [1,2].With continued exposure to COPD risk factors and the aging of the population,the prevalence and burdens of COPD are projected to increase [3],especially in low-and middle-income countries [4].The prevalence of COPD in China was 13.7% among people aged 40 years or older [5] and accounted for almost 25%of all COPD cases globally[6].The Chinese government and society are concerned about preventing and treating COPD.From 2017 to 2021,three major national projects were established in a coordinated effort [7].Despite its high prevalence,disability rates,and significant impact on work productivity,64% of the public is still ‘completely unaware’ of COPD[8].

Early identification of individuals with a high-risk of COPD and targeting them for preventive interventions is important in COPD prevention [9].Age ＞35,smoking history,and respiratory symptoms are commonly used to define a high-risk COPD population[10,11].The incidence of COPD in high-risk people aged ≥40 years accounts for 89.95% [12].Previous studies have focused on exploring different strategies for COPD prevention or management.Ghambarian et al.[9]presented a stepwise target group-oriented prevention (STOP) strategy,and the model suggests target groups for prevention based on identifying high-risk categories and age groups.Engel et al.[13] suggested manual therapy and exercise during the ‘a(chǎn)t risk’ stage.Chinese researchers actively call for constructing a “health promotion,prevention,diagnosis,control,treatment,rehabilitation”six-in-one working system for COPD[14].In the Lancet Commission on COPD,the researchers propose a novel classification of COPD encompassing five types based on the predominant risk factors-genetics,early-life events,pulmonary infections,tobacco smoke exposure,and air pollution [15,16],which would offer many opportunities for prevention.

Translating clinical evidence into prevention behaviors and healthcare practice is complex and difficult and requires behavior change [17].The theoretical model of knowledge,attitude,and practice (KAP) [18] holds that healthy behaviors may be formed only when positive and correct beliefs and attitudes are established.Although researchers from different countries have explored various strategies for COPD prevention among a high-risk population for COPD,there have been few reports considering the awareness of the targeted population,which has been shown to have key interventions that can reduce the burden of COPD[4,19].Therefore,more extensive efforts are urgently needed to explore prevention strategies and understand the KAP of disease prevention among a high-risk population for COPD.

This study aimed to assess the situation of KAP regarding disease prevention among a high-risk population for COPD and to examine the differences in target populations’ KAP according to their demographic characteristics.

2.Methods

2.1.Study design and participants

This study used a cross-sectional design.Convenience sampling was conducted to select high-risk populations with COPD who visited the respiratory outpatient department of a tertiary hospital in Chongqing from January to December 2021.Participants were eligible if they met the definition of being at high-risk for COPD based on the guidelines of the primary diagnosis and treatment of COPD(a COPD-PS score ≥5) [10,20]and volunteered for this study.Exclusion criteria included 1) those unable to complete the investigation due to a lack of communication equipment,such as a telephone or mobile phone,and 2)those with critical or end-stage diseases.The number of questionnaire items in this study is 39,and 5-10 times the number of questionnaire items used to calculate the sample size[21].Therefore,at least 195 respondents are required in this study.

2.2.Instrument

We conducted a cross-sectional study with a self-designed questionnaire among a high-risk population for COPD.Guided by KAP,the questionnaire was developed via a systematic literature review and two rounds of expert consultation.First,the literature review was conducted by searching the following keywords on PubMed,Information Sciences Institute(ISI),Web of Science,China National Knowledge Infrastructure (CNKI),Wanfang,and Weipu databases:“chronic obstructive pulmonary disease,”“high-risk,”or“at risk,”“risk factor,”“knowledge,attitude and practice,”or“KAP”and “prevention.” Meanwhile,the self-designed questionnaire referred to the maturity scale: 1) the Bristol COPD Knowledge Questionnaire (BCKQ) [22];2) the Health Promotion Lifestyle Profile-II [23];and 3) the Champion Health Belief Model Scale(CHBMS) [24].After further summary and refinement,the initial questionnaire themes and items were formed,including basic characteristics of participants (gender,age,educational level,occupation,type of medical insurance,annual household income,current smoking status,passive smoking status,dust work experience,frequency of cooking,and regular physical exercise status)and KAP for preventing COPD among a high-risk population.Five experts evaluated the KAP questionnaire of disease prevention among the high-risk population for COPD.The expert group consisted of one medical expert and four nursing experts with more than ten years of work experience in the respiratory field,had a bachelor’s degree or above,had intermediate and above professional titles,were familiar with this research content,and volunteered to assist with this study.Kendall’sWfor the two rounds of expert consultation were 0.588 and 0.302,respectively (P＜0.05).Each questionnaire item’s average item-level content validity index(I-CVI) was 0.951.

The final version of the questionnaire consisted of 39 items and 3 dimensions: knowledge,attitude,and practice.The knowledge dimension(21 items,K1-K4,K7 included a,b,c,and d;K8 included a,b,c,d,and e) ranged from 1 (very unclear) to 5 (very clear).Questions of the knowledge dimension mainly focused on the awareness of COPD and lung function tests,the general concept of COPD (epidemiology,etiology,common symptoms,risk factors),and prevention (smoking cessation,vaccinations,diet,exercise).The attitude dimension (9 items,A1-A9) ranged from 1 (strongly disagree)to 5(strongly agree).Questions of the attitude dimension mainly focused on COPD susceptibility,COPD severity,benefits of lung function tests,disorders of lung function tests,health motivation,and self-efficacy.The practice dimension (9 items,P1-P9)ranged from 1 (never) to 5 (always).The COPD prevention-related practice dimensions included health responsibilities,nutrition,exercise,and preventive behavior.The higher the score,the better the respondents’KAP of COPD prevention.Before the formal survey,the questionnaire was used for a preliminary experiment with an overall Cronbach’s α coefficient of 0.937.Through the exploratory factor analysis of 241 questionnaires,the KMO (Kaiser-Meyer-Olkin) value of the questionnaire was 0.921,and the approximate chi-square value was 7,256.271 (P＜0.001).The Cronbach’s α coefficient for KAP was 0.963,0.879,and 0.940,respectively,and the overall Cronbach’s α coefficient of the questionnaire was 0.946.As the number of items in each dimension is different,to facilitate the score analysis of each dimension,the score of the KAP questionnaire was standardized,and the score of each dimension was calculated: score=actual score/the highest possible score × 100.The knowledge,attitude,and practice dimensions scores were divided into three grades: good,moderate,and poor [25],with good ＞85 points,poor ＜60 points,and 60-85 points as moderate.

2.3.Data collection

We trained two data collectors on the questionnaire’s content and skills in conducting a telephone questionnaire survey [26].Before the survey,a short message was sent to the participants through the hospital cloud follow-up platform to explain the purpose,content,and method of the survey and emphasize privacy protection.After the investigation began,informed consent was given orally,and the knowledge,attitude,practice,and other related COPD prevention questions were asked individually.The call duration for each participant ranges from about 5 to 10 min.Eight hundred thirty-two mobile phone numbers were dialed,and 241 (28.7%) were effectively answered.

2.4.Statistical analysis

Data were analyzed using SPSS software (version 20.0).The numbers,percentages,mean,and standard deviations (SD) were used to present quantitative data.ANOVA andt-tests were applied to examine the differences in KAP among demographics variables.And comparison among groups was conducted by “post hoc”command.P＜0.05 was considered statistically significant.

2.5.Ethical considerations

The study was approved by the Medical Ethics Committee of the People’s Hospital of Dazu,Chongqing,China(2021LLSC045).Before obtaining the data,the participants were briefed about the purpose of the study.All participants volunteered to participate in this survey.

3.Results

3.1.Participants characteristics

Among the 241 participants in the high-risk population for COPD,196 were males (81.3%),45 were females (18.7%),78.01%(188/241) were aged from 50 to 69,76.35% (184/241) had moderate and low educational backgrounds,22.4%(54/241)and 32.8%(79/241) were farmers,and 53.5% (129/241) had medical insurance.The annual household income was ＞30,000 CNY,which accounted for 35.7% of the participants (n=86),followed by 10,000-20,000 CNY,which accounted for 31.5%of the participants(n=76).There were 191 smokers(79.3%)and 177 passive smokers(73.4%).The highest cooking frequency was regular,which accounted for 43.6%(105/241);209 people(86.7%)did not engage in regular physical exercise.

3.2.Overall status of KAP regarding disease prevention in a highrisk population for COPD

The overall KAP score was 68.29 ± 12.91,and the scores of the three dimensions of knowledge,attitude,and practice were 68.75±18.07,71.13±15.09 and 65.00±20.93,respectively.In this survey,the scores of the knowledge and attitude dimensions of COPD prevention were mainly 60-85,resulting in 61.4%and 67.6%proportions for those dimensions,respectively,which indicates that the people at high-risk of COPD exhibited moderate knowledge and attitude toward COPD prevention.Among them,76.8%had a low KAP score for COPD prevention,as shown in Table 1.

Among the items regarding the knowledge of COPD prevention,the people at risk of COPD constantly agreed that smoking is closely related to lung health.The three items(K10,K9,K8a)scored highest in the knowledge dimension.Meanwhile,More than half of them had inadequate knowledge about COPD mechanism,prevention in vaccination,and early lung health events,and the three items(K11,K8e,K13) scored lowest in the knowledge dimension.For the attitude about COPD prevention,item A4 “I would like to find health problems earlier,” scored the highest,indicating that with social progress and development,people’s concept of health has gradually changed,which showed an active desire for health.Even so,item A8“if necessary,I am confident that I can arrange a time to check regularly whether I suffer from COPD,” scored lowest,reflecting a passive attitude toward implementing COPD prevention.Regarding the practice of COPD prevention,the score of the practice dimension was the lowest,and those with scores less than 60 accounted for 35.3%,highlighting the vulnerable spot of COPD prevention intervention (Table 2).

3.3.Influencing factors of KAP of disease prevention in a high-risk population for COPD

There were significant differences in the overall KAP scores for disease prevention among the high-risk group for COPD based on sex,educational level,occupation,type of medical insurance,current smoking status,and passive smoking status (P＜ 0.05)(Table 3).

Table 1 Classification of KAP of disease prevention in a high-risk population for COPD(n=241).

Table 2 The highest and lowest scores of the three items in knowledge,attitude,and practice dimensions (n=241).

The male COPD high-risk group has better KAP scores towards COPD prevention than the female group(P＜0.05).The group aged≥70 showed worse knowledge and attitude towards COPD prevention than those aged ≤49 (P＜0.05).With regard to the education level,the COPD high-risk group with senior high or above has better knowledge and attitude than the group of primary school and below (P＜0.05).Farmers showed a lower score in the attitude and practice of COPD prevention compared to staff of government organizations,enterprises,and institutions(P＜0.05).The score was higher among the COPD high-risk group with medical insurance for urban workers compared to the group with the new rural cooperative medical system(P＜0.05).Additionally,Smoking and passive smoking groups have higher recognition of the knowledge but the lower practice of COPD prevention(P＜0.05).

4.Discussion

COPD is a complex,multi-factorial,but preventable disease.Previous studies [27,28] have shown a cost-effective advantage of early screening among people with high COPD risk,who can receive an increase in quality-adjusted life years (QALYs) by 0.02-0.28 units over those who did not.However,there is a low awareness among a high-risk population for COPD regarding early screening of respiratory diseases,reduction of exposure to risk factors,prevention,and acquisition of scientific knowledge[29].However,proper knowledge of the disease and controlling risk factors is essential for COPD prevention[ [30].To better understand the characteristics and weak spots in COPD prevention among a high-risk population for COPD,more evidence on the target populations’ KAP toward COPD prevention is needed.

Tobacco exposure remains the key environmental risk factor for COPD.As in our study,79.25% of the people at risk of COPD currently smoke,and nearly 73.44% passively smoke.We found,quite interestingly,that the items “smoking or passive smoking makes people more likely to suffer from COPD,”“stopping smoking will slow down further lung damage,” and “stopping smoking usually results in improved lung function” obtained the highest scores in the knowledge dimension,which indicated that the people at risk of COPD constantly agreed that smoking is closely related to lung health.Inconsistently,the smoking and passive smoking groups have lower practices of COPD prevention.Additionally,doctors’brief advice on quitting smoking can significantly improve smoking cessation rates [31].Therefore,it is suggested to strengthen smoking cessation publicity and introduce short cessation training for medical staff to help control the main risk factors for COPD.Moreover,a previous study emphasized that it is important to look beyond the COPD tobacco pairing and consider early lung health [32].We observed a poor understanding of risk factors,especially early-life events such as childhood respiratory infections,among a high-risk population for COPD,which would open novel windows of opportunity for prevention.

In our study,the scores of the attitude dimensions were 71.13 ± 15.09,and most of the people with a high-risk for COPD wanted to find health problems earlier 3.79±1.00 and agreed that it is important to take part in activities to improve health 3.63 ±1.09,which is considered to be moderate regarding disease prevention.This is consistent with the report “Grading diagnosis and treatment of chronic obstructive pulmonary disease in China(2020)” [33],which notes that more than 70% of the respondents are willing to acquire knowledge about the prevention and treatment of COPD.Although they have an active attitude for health,they generally lack the understanding and action of COPD prevention,such as vaccination,lung function tests,and risk factors for early-life events.It is necessary to take effective measures to promote awareness of the benefits and cost-effective advantages of COPD prevention among a high-risk population for COPD.

The score of the practice dimension of COPD prevention was the lowest among the three dimensions,and those with scores less than 60 accounted for 35.3%,highlighting the vulnerable spot of COPD prevention intervention.This is consistent with Cai’s study[34],which showed that people at high-risk for COPD were willing to spend on health but did not put the obtained health information into action and practice.Meanwhile,Liu’s studies [35,36] proved poor health behavior with a lack of autonomy and control in COPD prevention and treatment.A survey of the characteristics and health burden of the high-risk population for COPD in China showed that the inner consciousness of risk for disease occurrence is weak.Only 6.7% of the people have subjective risk awareness of disease occurrence[37].This is probably because COPD is insidious,with a slow progression,and easy to ignore.In addition,the public overlooked the primary prevention of the high-risk population for COPD due to the current overall medical environment that emphasizes treatment and neglect prevention [38].Nevertheless,COPD is both preventable and treatable.It is necessary to pay attention to a six-in-one [14] (health promotion,prevention,diagnosis,control,treatment,and rehabilitation) work system for dealing with COPD,strengthen the management and health education of high-risk groups for COPD,take active measures to reduce risk factor exposure,and establish early health promotion behaviors to prevent or reduce the occurrence of COPD effectively.

COPD has traditionally been considered a disease caused by smoking,primarily affecting men over 60 [32].Previous studies have shown a significantly higher prevalence,misdiagnoses,and/or under-diagnoses among women than men in COPD[39-41].In our research,the female COPD high-risk group has worse KAP scores toward COPD prevention than the male group (P＜0.05).It is urgently needed to pay attention to the gender differences of COPD prevention with risk factors for indoor air pollution(household air pollution from burning solid fuels for cooking or heating) [42] in the female group.The incidence of COPD increases with the population aging,and our study found that the group aged 70 or above showed worse knowledge and attitude toward COPD prevention than those aged 49 or below(P＜0.05).It is imperative to consider improving the KAP of COPD prevention in older adults.Among the high-risk populations for COPD,farmers and those with a new rural cooperative medical system showed a poor attitude and practice of COPD prevention.

Meanwhile,the target people with low educational background have worse KAP of COPD prevention.It was similar to Liu’s study,which showed that [35] people at high-risk of COPD with lower educational levels have inferior health self-efficacy.This is probably due to poor knowledge acquisition ability and poor understanding of knowledge.More attention should be given to education in COPD prevention for this special group.

5.Limitations

There are a few limitations in this study.First,data were collected via a self-rated questionnaire because no standardized instrument could be used.However,we used a research framework to accurately reflect the KAP of COPD prevention among a high-risk population for COPD.The questionnaire was developed via a systematic literature review and two rounds of an expert consultation,and the reliability was relatively high.Second,we conducted convenience sampling and recruited participants from a respiratory outpatient department of one tertiary hospital in Chongqing,limiting the comprehensive findings.Further research should use randomized sampling and select a sample from every city to guarantee a better representation.

6.Conclusions

This study showed that the population with a high-risk of COPD had a moderate KAP about COPD prevention.People with a highrisk of COPD have an active desire for health.Meanwhile,they constantly agreed that smoking is closely related to lung health.Still,they generally lack the action of COPD prevention,such as vaccination and lung function tests,and with an insufficient understanding of risk factors for early-life events.The research provides a reference for formulating targeted interventions of COPD prevention among the population with high-risk COPD.The factors affecting the COPD prevention of KAP were gender,educational level,occupation,type of medical insurance,smoking,and passive smoking.We also identified the differences in the demographic of COPD prevention in the target population.With the concept of“population medicine”[43]for COPD prevention,it is necessary to incorporate the characteristics and needs of the group to formulate further health management plans after evaluation and analysis.

Funding

Nothing to declare.

CRediT authorship contribution statement

Lulu Zhao:Conceptualization,Methodology,Investigation,Data curation,Formal analysis,Writing-original draft,Writing-review&editing.Qinghua Zhao: Conceptualization,Methodology,Project administration,Supervision,Writing-review&editing.

Data availability statement

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Declaration of competing interest

The authors have declared no conflict of interest.

Acknowledgments

We would like to express our gratitude to all collaborating participants.

Appendix A.Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.ijnss.2023.03.012.