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Abstract
Objectives This study aimed to evaluate the knowledge, attitudes and practices (KAP) of patients with chronic respiratory diseases towards pulmonary rehabilitation.
Design Cross-sectional, web-based questionnaire study.
Setting Tertiary healthcare hospital in Taiyuan, Shanxi Province, China.
Participants A total of 511 patients with chronic respiratory diseases were recruited from the hospital’s outpatient and inpatient departments. After data cleaning, 501 valid responses (98.04% valid response rate) were analysed. Participants were aged 18 or older, able to complete the questionnaire independently or with assistance and included individuals from diverse demographic backgrounds.
Primary and secondary outcome measures Primary outcomes included KAP scores related to pulmonary rehabilitation. The secondary outcome assessed the association between demographic factors (age, gender, income, education, smoking status) and KAP scores using structural equation modelling (SEM).
Results The mean KAP scores were 1.26±2.85 for knowledge, 30.46±3.63 for attitudes and 34.58±5.55 for practices. SEM analysis showed that knowledge directly influenced attitudes (β=−0.538, p<0.001) and both knowledge (β=0.668, p<0.001) and attitudes (β=0.668, p<0.001) significantly influenced practices. Additionally, demographic factors, such as monthly household income, type of chronic respiratory disease, educational level and smoking status were significantly associated with variations in KAP scores (all p<0.05).
Conclusions Patients demonstrated poor knowledge, generally positive attitudes, and moderate practices regarding pulmonary rehabilitation. Tailored educational interventions focusing on bridging the knowledge gap and promoting positive behavioural changes are essential for improving pulmonary rehabilitation engagement among chronic respiratory disease patients.
Trial registration number ChiCTR2400080271.
- Chronic airways disease
- Rehabilitation medicine
- Cross-Sectional Studies
- Surveys and Questionnaires
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The study analysed the impact of multiple demographic factors on knowledge, attitudes and practices (KAP) scores among patients with chronic respiratory diseases.
A validated, self-designed questionnaire with pilot testing was used to ensure data reliability.
The cross-sectional design limits the ability to infer causality between KAP variables.
Reliance on self-reported data may have introduced response bias.
Conducting the study at a single hospital may limit the generalisability of findings.
Introduction
Chronic respiratory diseases pose a significant global health challenge, affecting hundreds of millions of people worldwide.1 One prominent example is Chronic Obstructive Pulmonary Disease (COPD), characterised by persistent airflow limitation and associated respiratory symptoms.2 Within the spectrum of managing these conditions, pulmonary rehabilitation (PR) stands out as a vital component, playing a crucial role in sustaining and improving symptoms, physical function and quality of life.3 4 PR has been extensively studied in patients with COPD, particularly for its effects on improving functional status and gas exchange. Current evidence indicates that PR not only enhances exercise capacity but also has a positive impact on arterial carbon dioxide pressure (PaCO2) and thoracic mobility in COPD patients. In patients with hypercapnia, PR significantly reduces PaCO2 levels and demonstrates marked improvements in functional outcomes, such as walking distance. Additionally, PR contributes to increased thoracic mobility, particularly in the upper chest (eg, at the angle of Louis), with improvements positively correlated with lung function measures (forced expiratory volume in one second (FEV1), forced vital capacity (FVC)) and negatively correlated with PaCO2.5 6 This approach is integral to addressing the physical and psychological symptoms of chronic respiratory diseases, aiming to enhance the overall quality of life and reduce hospitalisation rates.7 8 Despite its evident importance, the widespread incorporation of PR practices remains insufficient.4
PR has demonstrated positive effects in post-COVID-19 patients across various studies. A systematic review with 677 participants indicated that PR improved dyspnoea, physical function and quality of life though pooled analysis showed no significant changes due to study heterogeneity.9 Another study on a multicomponent exercise programme (MEP) showed significant improvements in cardiorespiratory performance and reduced dyspnoea, with benefits maintained at a 2-year follow-up.10 In older adults, a short PR programme resulted in significant improvements in frailty and physical capacity.11 Early physiotherapy in intensive care unit (ICU) patients improved lung function, muscle strength and gas exchange.12 A meta-analysis showed that PR positively impacted dyspnoea, physical function and psychological state in long COVID-19 patients, with face-to-face PR being more effective for physical quality of life.13 Lastly, another review found that PR was effective in improving health outcomes in subacute and long COVID-19, although biases in the studies suggested caution in interpreting results.14
The KAP model posits that individual behaviours are influenced by their knowledge and attitude.15 In the field of public health, the examination of behavioural practices is often accompanied by the evaluation of knowledge and risk perception, commonly conducted through KAP questionnaires.16 Understanding the awareness, attitudes and participation of patients in respiratory rehabilitation is key to identifying gaps and challenges in current medical practices. Exploring patients’ perceptions and behaviours provides insights for improving respiratory rehabilitation services. This comprehensive understanding of patient comprehension and acceptance is vital for developing effective health education and outreach strategies. Additionally, while previous research has focused on patients’ KAP regarding COPD and healthcare professionals’ KAP regarding PR, a comprehensive exploration of KAP specifically related to respiratory rehabilitation in patients with chronic respiratory diseases is lacking in the existing literature.17 18 Thus, this study aimed to investigate the KAP of patients with chronic respiratory diseases towards respiratory rehabilitation using a questionnaire.
Materials and methods
Study design and patients
This cross-sectional questionnaire-based study was conducted among patients with chronic respiratory diseases in the outpatient or inpatient departments of the Department of Respiratory and Critical Care Medicine of a tertiary hospital in Taiyuan, Shanxi Province, China, between 25 January 2024 and 25 February 2024. The inclusion criteria targeted patients with chronic respiratory disease,19 who received either outpatient or inpatient treatment at the Department of Respiratory and Critical Care Medicine of our hospital in Shanxi Province during the study period. Participants were required to be 18 years or older and capable of completing the questionnaire. They needed to be clearly conscious and able to answer the questionnaire, with assistance available from family members or researchers if needed. The exclusion criteria focused on individuals who declined or were unwilling to participate or were unable to provide informed consent, without excluding those with coexisting conditions.
Questionnaire development
The questionnaire design adhered to pertinent guidelines.19 Subsequent to the initial draft creation, the questionnaire underwent revisions following feedback from two experts in the Department of Respiratory and Critical Care Medicine and was subjected to a small-scale pilot test involving 56 respondents. The reliability of the questionnaire was evaluated using Cronbach’s α, yielding a value of 0.831, indicating the questionnaire has good internal consistency.
The final questionnaire, developed in Chinese (a version translated into English was attached as an online supplemental appendix), covers data collection across four dimensions, comprising a total of 41 items. These dimensions include demographics with 11 items, the knowledge dimension with 11 items (online supplemental table 1), the attitude dimension with 8 items (online supplemental table 2) and the practice dimension (willingness of participants to perform these actions in the future) with 11 items (online supplemental table 3). The scoring for statistical analysis is determined by the chosen options and quantities of the items. In the knowledge dimension, opting for ‘well-known’ yields 2 points, ‘heard of’ yields 1 point and ‘unclear’ yields 0 points, resulting in a possible score range of 0 to 22 points. Using a 5-point Likert scale for the attitude and practice dimensions, ranging from ‘very positive’ (5 points) to ‘very negative’ (1 point), specific scoring criteria were outlined. For the attitude dimension, items 1/3/5/7 are scored as a=5, b=4, c=3, d=2, e=1, and items 2/4/6/8 are scored conversely. This yields a possible score range of 8 to 40 points. Similarly, for the practice dimension, all 11 items are scored uniformly. After participants complete the questionnaire, the average score in the knowledge dimension is categorised into inadequate knowledge (0–10 points), moderate knowledge (11–15 points) and sufficient knowledge (16–22 points). In the attitude dimension, an average score between 8 to 20 points is defined as a negative attitude, 21 to 28 points as a neutral attitude and 29 to 40 points as a positive attitude. In the practice dimension, an average score within the range of 11 to 27 points is labelled as negative practical behaviour, 28 to 39 points as moderate practical behaviour and 40 to 55 points as positive practical behaviour.
Supplemental material
Data collection and quality control
By comprehensive sampling, this study surveyed both outpatient and inpatient patients who met inclusion/exclusion criteria and were able to complete the questionnaire, with assistance from family members or researchers if needed, regardless of chronic, acute or acute exacerbations in chronic patients. The three researchers were all physicians from the Department of Respiratory and Critical Care Medicine of our Hospital, among whom two were deputy chief physicians and one was a resident doctor. All three of them have rich knowledge and clinical experience in respiratory rehabilitation. The researchers issued questionnaires through the QR code generated by the online platform of SoJump (https://www.wjx.cn/), guided the respondents to enter the online platform of SoJump to answer the questionnaire by scanning the QR code through WeChat app on their mobile phone, and supervised the whole questionnaire answering process, so as to ensure the respondents’ understanding of the questionnaire content and the completeness of the questionnaire.
To enforce quality control measures, respondents were mandated to complete the questionnaire via WeChat login, with each IP address restricted to a single completed questionnaire. Questionnaires completed in less than 120 s, responses deviating from normal logic or instances where the same option was selected for any part of the KAP questionnaire were deemed invalid.
Sample size calculation
To determine the required sample size for a cross-sectional study, the following formula is used:
n = (Z² × P × (1−P)) / E²
where, n is the required sample size; Z is the z-value corresponding to the desired confidence level (for a 95% confidence level, Z=1.96); P is the estimated proportion of the population (commonly assumed to be 0.5 when unknown); E is the margin of error (typically set at 0.05). For a 95% confidence level, with p=0.5 and E=0.05, the formula calculates as: n = (1.96² × 0.5 × (1–0.5)) / 0.05² = 384.16
Statistical analysis
Data analysis was conducted using the SPSS 26.0 (IBM, Armonk, NY, USA). Continuous data are presented as means and SD, while categorical data are expressed as n (%). Continuous variables underwent a normality test, with the t-test for normally distributed data and the Wilcoxon Mann-Whitney test for non-normally distributed data when comparing two groups. For three or more groups with normally distributed continuous variables and uniform variance, analysis of variance was used for comparisons, while the Kruskal-Wallis test was employed for non-normally distributed data. Pearson’s correlation analysis and structural equation modelling (SEM) were used to explore the relationships between knowledge (K), attitude (A) and practice (P). A two-sided p value less than 0.05 was considered statistically significant.20 21
Patient and public involvement
Patients or the public were not involved in the design, conduct, reporting or dissemination of our research.
Results
Demographic characteristics
In this study, a total of 511 questionnaires were initially collected from all eligible patients with chronic respiratory diseases. After excluding one case of age outliers, two cases of choosing no underlying disease and other diseases at the same time and seven cases of choosing all the consent options for one of the dimensions of the KAP, 501 cases of valid data were left in the end (figure 1). For all valid questionnaires, the overall Cronbach’s α coefficient was 0.780, with a Kaiser-Meyer-Olkin (KMO) of 0.900 (p<0.001), which further verified that the reliability and validity of the questionnaire were good. Of participants aged 64.57±15.35 years, 326 (65.07%) were male, and 338 (67.47%) had an education of junior high school or below. Among the 501 participants with chronic respiratory diseases, 195 (38.92%) were never smokers. The most common chronic respiratory disease among these participants was COPD, with 128 cases. Their mean KAP scores were 1.26±2.85 (possible range: 0–22), 30.46±3.63 (possible range: 8–40) and 34.58±5.55 (possible range: 11–55), respectively (table 1).
Demographic characteristics
The flowchart of this study.
Distributions of options in KAP dimensions
For most of the topics in the knowledge dimension, more than 90% of patients reported that they were unsure about them. The question with the highest proportion of patients choosing the ‘Heard of’ option was ‘Malnourished patients with chronic respiratory diseases may require nutritional support because lower BMI compared with normal-weight patients can lead to reduced physical fitness and an increased risk of mortality’ (K10, 25.75%). On the other hand, the question with the highest proportion of patients choosing the ‘Unclear’ option were ‘While engaging in resistance training, maintaining proper breathing is essential to avoid conscious breath-holding’ (K8, 95.41%) (online supplemental table 1).
With regard to PR, 59.08% of patients recognised its importance in relieving symptoms and improving quality of life (A1). 46.91% were not concerned about changes in lifestyle and habits (A2) and 40.72% were not concerned about excessive effort (A4). In addition, 68.06% and 70.86% were very hopeful of receiving encouragement from family and friends (A5) and help from healthcare professionals (A7), respectively. However, 65.67% felt very confused and uneasy about how to adhere to the treatment plan for PR (A8) (online supplemental table 2).
The different frequencies of patients on different practice behaviours reflect their willingness to perform these actions in the future. For instance, 36.93% indicated that they would always perform inspiratory muscle training as prescribed (P6). Similarly, 61.48%, 58.28% and 63.07% expressed intentions to frequently engage in PR (P1), pay attention to diet and weight control (P4) and perform aerobic exercise (P7). 71.06% were sometimes evaluated for respiratory function and physical condition (P2). 64.07% rarely attended various training programmes (P3) (online supplemental table 3).
Correlation analysis
Pearson’s correlation analysis shows that knowledge (r=0.101, p=0.023) and attitude (r=0.423, p<0.001) are related to practice; however, the correlation between knowledge and attitude is not significant (r=0.019, p=0.670) (table 2). Furthermore, SEM revealed a significant influence on knowledge on attitude (β=−0.538, p<0.001) while both knowledge (β=0.668, p<0.001) and attitude (β=0.668, p<0.001) have significantly influence on practice (figure 2 and table 3). A fairly good model with Chi-square minimum (CMIN)/degrees of freedom (DF) = 5.436, root mean square error of approximation (RMSEA) = 0.094, incremental fit index (IFI) = 0.808, Tucker-Lewis index (TLI) = 0.789 and comparative fit index (CFI) = 0.807 was fitted (table 4).
Pearson’s correlation analysis
Structural equation modelling results
Structural equation modelling model
Structural equation modelling of knowledge, attitude and practice relationships.
Moreover, analysis of the demographic characteristics of the participants found that patients with different household average monthly per capita income and chronic respiratory disease conditions were more likely to have different KAP scores (all of p<0.001). Education (p<0.001 and p<0.001) and underlying disease conditions (p=0.019 and p=0.001) were also likely to result in different levels of knowledge and practice. In addition, patients with different places of residence (p<0.001) and types of occupation (p<0.001) were more likely to have different knowledge scores. Meanwhile, differences in marital status produced differences in attitude (p<0.001). Further, patients who smoke are more likely to have attitude and practice scores that differ from non-smoking patients (p<0.001 and p=0.004) (table 1).
Discussion
Patients with chronic respiratory diseases demonstrated a significant deficiency in knowledge, positive attitudes and suboptimal practice towards PR. Our findings indicate that knowledge directly influences attitudes, and both knowledge and attitudes play significant roles in shaping practices. This relationship underscores the need for targeted interventions to improve knowledge, which could in turn positively impact attitudes and practices.
The research findings reveal that the mean scores for KAP were consistently low, indicating a substantial gap in understanding and engagement with respiratory rehabilitation measures within this population. These findings align with the literature on chronic respiratory diseases, where inadequate knowledge is reported.22 However, while both knowledge and attitude contribute to practice, the low knowledge scores in this study highlight a particularly severe knowledge gap that may hinder effective practice, despite generally positive attitudes. The observed correlations between knowledge and practice, as well as attitude and practice, are consistent with previous studies emphasising the importance of knowledge and positive attitudes in influencing health-related behaviours.23 The correlations observed between knowledge and practice, as well as between attitude and practice, align with previous studies that emphasise the importance of knowledge and positive attitudes in influencing health-related behaviours,24 suggesting a more complex relationship between these variables. Despite the low levels of knowledge, the relatively positive attitudes observed in this study may be attributed to patients’ trust in their doctors, which could lead them to follow medical advice even when their own understanding is limited.
The study identified several demographic factors as contributors to variations in KAP scores. These findings corroborate existing literature that recognises the influence of socioeconomic status on health outcomes and behaviors.25 26 Moreover, the SEM analysis indicating a significant inverse relationship between knowledge and attitude contradicts some conventional assumptions and prior research.27
Our analysis further suggests that certain demographic characteristics, such as education and income level, significantly affect knowledge and practice levels, indicating a need for tailored interventions. Previous research has shown that cultural and socioeconomic factors influence how health information is interpreted and applied.28 To address these differences and improve clinical practice, targeted and tailored interventions are crucial. Education programmes that consider diverse demographic characteristics, such as income, education and smoking status, may lead to more effective improvements in KAP outcomes. This recommendation aligns with existing literature emphasising the importance of tailored interventions for specific population groups.29 30 Moreover, interventions should go beyond the mere provision of information and actively address attitudinal factors. Incorporating motivational strategies, such as counselling or psychoeducational approaches, could bridge the gap between knowledge and practice, enhancing adherence to respiratory rehabilitation recommendations.31 32
The study demonstrates a substantial gap in participants’ knowledge regarding crucial aspects of respiratory rehabilitation. These knowledge deficits span various areas, including the role of aerobic and resistance training as well as the importance of nutritional support for malnourished patients. To improve clinical practice, tailored educational programmes should focus on these specific knowledge dimensions where participants demonstrated limited awareness. Additionally, emphasising the importance of personalised comprehensive interventions aligns with evidence-based guidelines for respiratory rehabilitation, promoting a strategic and focused approach to address the identified deficiencies and enhance overall clinical practice.19
In terms of attitudes, a large majority expressed positive attitudes, acknowledging the therapeutic importance of respiratory rehabilitation in alleviating symptoms and enhancing their quality of life. Conversely, a noteworthy proportion expressed concerns, including doubts about its effectiveness and apprehensions regarding lifestyle alterations. Notably, a significant number of participants expressed uncertainty about adhering to the treatment plan, revealing potential barriers to the successful implementation of respiratory rehabilitation. To address these diverse attitudes and enhance clinical practice, interventions should target both positive reinforcement and addressing concerns. The educational programmes can emphasise success stories and evidence of the efficacy of respiratory rehabilitation. Addressing these barriers through practical support and positive reinforcement could help foster a more optimistic and confident outlook on rehabilitation adherence.8 33 Furthermore, strategies such as counselling sessions and social support, involving family and friends, may enhance adherence by addressing concerns in a supportive context.33 34
The study also highlights low engagement in practice activities related to respiratory rehabilitation, with a considerable number of participants infrequently engaging in critical practices, such as respiratory training and dietary control. Addressing these deficiencies requires a focus on self-management and adherence support to improve patient outcomes. Strategies to improve practice adherence may include personalised motivational techniques and technology-based interventions like mobile apps or wearable devices for ongoing support.35–38 Furthermore, engaging social support networks, such as peer mentoring or support groups, may foster adherence and build a sense of community among participants.39 40
This study’s limitations include its cross-sectional design, which only captures a momentary view of patients’ KAP, without showing causation or changes over time. Then, the multiple statistical tests lack of a priori planning which might influence the results. Additionally, potential response bias in self-reported data may affect accuracy. A lack of patient participation could have further influenced the findings, possibly missing important additional knowledge gaps related to general health or PR. The complexity of the questions in the questionnaire may have also impacted patient responses. Furthermore, the results may not be generalisable to individuals with higher education levels or differing demographic characteristics. In addition, we did not consider whether patients had participated in PR in the past at the beginning of the questionnaire design, which might have impacted on their KAP. Nevertheless, one of the key strengths of this study is the use of a questionnaire to assess the KAP of patients regarding PR. This approach effectively demonstrated significant knowledge deficits while highlighting generally positive attitudes towards PR. Additionally, the questionnaire provided valuable insights into patient behaviour and perceptions, helping to identify specific areas for improvement in patient education and engagement with respiratory rehabilitation programmes.
Conclusion
In conclusion, patients with chronic respiratory diseases were severely lacking in knowledge, and many were lacked positive attitudes towards and/or had suboptimal practice regarding PR.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by Clinical research ethics committee of Shanxi Bethune Hospital (approval number: LYLL-2023-002/PJ04). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
We greatly appreciate the support of all patients for their voluntary participation in this study.
Footnotes
LS and LW contributed equally.
Contributors LS: supervision, project administration, methodology, formal analysis, data curation, resources, writing – original draft, writing – review and editing. LW: investigation, validation, conceptualisation, formal analysis, data curation, writing – review and editing. JD and XZ: conceptualisation, methodology, investigation, writing – review and editing, resources. RW: conceptualisation, methodology, investigation, writing – original draft, writing – review and editing, resources. XB and XL: methodology, investigation, data curation, conceptualisation, project administration, resources, supervision, writing – review and editing. YC: methodology, investigation, conceptualisation, project administration, resources, supervision, writing – review and editing. SW: methodology, investigation, funding acquisition, conceptualisation, project administration, resources, supervision, writing – review and editing. LS is the guarantor responsible for the overall content.
Funding The study was supported by the Research and Innovation Team Project for Scientific Breakthroughs at Shanxi Bethune Hospital(No. 2024OAXIANG01), Fundamental Research Program of Shanxi Province (No. 202303021221192), Scientific and Technological Innovation Programs of Higher Education Institutions Shanxi (No. 2022L160), the Key Scientific Research Project of COVID-19 Infection Emergency Treatment of Shanxi Bethune Hospital (No. 2023xg01), COVID-19 Research Project of Shanxi Provincial Health Commission (No.2023XG001, No. 2023XG005), Four 'Batches' Innovation Project of Invigorating Medical through Science and Technology of Shanxi Province (No. 2023XM003), Cancer special Fund research project of Shanxi Bethune Hospital (No. 2020-ZL04) and External Expert Workshop Fund Program of Shanxi Provincial Health Commission (Proteomics Shanxi studio for Huang He professor).
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.