Factors influencing inhaled medication adherence among hospitalized patients with chronic obstructive pulmonary disease from rural and township areas of China with prior primary care experience: a mixed-methods study

Abstract

Patients with chronic obstructive pulmonary disease require long-term medication to control their symptoms. This study explored factors influencing adherence to inhaled medications in hospitalized patients with chronic obstructive pulmonary disease who resided in rural and township areas of China and had prior primary care experience, providing a basis for the development of targeted adherence-management programs. This was a single-center, parallel mixed-methods study conducted at Chongqing University Three Gorges Hospital. Purposive sampling was used to recruit hospitalized patients with chronic obstructive pulmonary disease for semi-structured interviews (qualitative component); convenience sampling was used to recruit patients for a questionnaire survey (quantitative component). Qualitative and quantitative data were collected concurrently and integrated during the interpretation stage. All participants resided in towns or rural areas of China, had prior experience of receiving care at primary-care centers, and were definitively diagnosed with chronic obstructive pulmonary disease at secondary or tertiary hospitals in China based on spirometric criteria (post-bronchodilator forced expiratory volume in one second / forced vital capacity < 0.7), according to the Global Initiative for Chronic Obstructive Lung Disease guidelines and Chinese chronic obstructive pulmonary disease diagnostic standards. Results were integrated and analyzed based on the Theory of Planned Behavior. In total, 19 and 265 patients participated in the qualitative and quantitative components, respectively. The mean (standard deviation) total medication adherence score of 265 patients in the survey was 46.14 (8.06) out of a maximum of 75, indicating a moderate level of adherence. The lowest mean (standard deviation) item score of 2.23 (0.82) was in the perceived behavioral-control dimension. Four themes were identified from in-depth interviews: trust-driven positive cycle of behavioral intention and symptom relief, health literacy-influenced negative cycle of behavioral attitude and cognitive bias, support-enhanced positive cycle of subjective norms and medication adherence, and perceived behavioral-control impairment and medication adherence challenges. Qualitative results complemented quantitative findings. Factors influencing medication adherence among hospitalized patients with chronic obstructive pulmonary disease who resided in rural and township China and had prior primary care experience are multidimensional, operating at individual, family, and societal levels. The perceived behavioral-control dimension had the lowest score, indicating that practical barriers such as economic constraints and device complexity are critical intervention targets. Future studies in community-based primary care settings are needed to validate these findings. Enhancing patients’ medication-use skills and health literacy should be prioritized in future management programs.