Received: 27 July 2019 | Revised: 2 February 2020 | Accepted: 4 March 2020

DOI: 10.1111/opn.12316

ORIGINAL ARTICLE

Self-management activities of older people with chronic

obstructive pulmonary disease by types of healthcare services
utilised: A cross-sectional questionnaire study

Satomi Kitamura MHS, RN, PhD Student1 |

1
Ayumi Igarashi PhD, RN, Assistant Professor | Yasuhiro Yamauchi PhD, MD, Lecturer2 |
Hideaki Senjyu PhD, PT, Professor3,4 | Takeo Horie PhD, MD, Assistant Manager5 |
1
Noriko Yamamoto-Mitani PhD, RN, Professor

1
Department of Gerontological Home Care
and Long-term Care Nursing/Palliative Care Abstract
Nursing, Division of Health Sciences and Aims and design: Various healthcare services in Japan provide self-management in-
Nursing, Graduate School of Medicine, The
University of Tokyo, Tokyo, Japan terventions for older people with chronic obstructive pulmonary disease (COPD). To
2
Department of Respiratory Medicine, The examine the influence of healthcare service utilisation on self-management activities,
University of Tokyo, Tokyo, Japan
we conducted a cross-sectional survey of older people with COPD who received care
3
Department of Clinical Mycobacteriosis,
Unit of Mycobacteriosis, Nagasaki
through outpatient clinics (OC), outpatient rehabilitation centres (OR) or home care
University Graduate School of Biomedical (HC) services.
Sciences, Nagasaki, Japan
4
Methods: The survey consisted of 34 originally developed self-report questions
Department of Respiratory Care and
Rehabilitation Center, Fukujuji Hospital, about three types of self-management activities: (a) strategies to minimise dysp-
Japan Anti-Tuberculosis Association, Tokyo, noea, (b) appropriate activities to maintain physical and mental health status and
Japan
5 (c) communication with healthcare professionals or family members. We compared
Department of Pulmonary Medicine,
Maebashi Redcross Hospital, Gunma, Japan self-management activities in each setting (OC, OR and HC) using logistic regression
analyses, controlling for dyspnoea level and age, which we chose as representative
Correspondence
Satomi Kitamura, Department of variables of disease severity.
Gerontological Home Care and Long-term
Results: Among the total sample (n = 81; mean age: 78.2 years old), participants in
Care Nursing/Palliative Care Nursing,
Division of Health Sciences and Nursing, the HC group (n = 25) had the most severe level of COPD, followed by those in the
Graduate School of Medicine, the University
OR (n = 31) and OC (n = 12) groups. Compared with participants from the OC group,
of Tokyo, Tokyo, Japan.
Email: snukina-tky@umin.ac.jp more participants from the OR and HC groups reported self-management activities,
such as “moving body corresponding to breathing” (OR: adjusted odds ratio [AOR],
6.71; HC: AOR, 6.98), “trying not to move quickly” (OR: AOR, 5.46), “avoiding suf-
focating movements” (HC: AOR, 7.37), “getting an influenza vaccination”(OR: AOR,
8.12; HC: AOR, 7.81), “stretching exercise” (OR: AOR, 6.42; HC: AOR, 16.76), “muscle
training” (OR: AOR, 8.49; HC: AOR, 9.73) and “discussing lifestyle goals with health-
care professionals” (HC: AOR, 5.75) after controlling for dyspnoea level and age.
Conclusions: Some self-management activities (such as breathing techniques and
home exercise) were associated with the use of OR or HC services, an effect persist-
ing after adjusting for degree of breathlessness and age.

Int J Older People Nurs. 2020;00:e12316. wileyonlinelibrary.com/journal/opn © 2020 John Wiley & Sons Ltd | 1 of 13
https://doi.org/10.1111/opn.12316
2 of 13 | KITAMURA et al.

Implications for practice: Findings suggest that we should provide additional services
such as OR and HC besides OC to older people with COPD who are unable to practice
self-management activities. We need to consider strategies to provide effective self-
management intervention in each healthcare service setting according to the unique
characteristics of each setting.

KEYWORDS

chronic obstructive pulmonary disease, dyspnoea, healthcare services, home care services,
outpatients, patient education, pulmonary rehabilitation, questionnaires, self-management,
surveys

1 | I NTRO D U C TI O N
For older people living with chronic illness, self-management is be-
coming increasingly important to improve clinical outcomes and
quality of life and to reduce the use of healthcare facilities (Grady &
Gough, 2014). This is also applicable to chronic obstructive pulmo-
nary disease (COPD), which is much more prevalent among people
aged 70 years or older than among younger generations (Fukuchi
et al., 2004). The Global Initiative for Chronic Obstructive Lung
Disease (GOLD) guidelines highlight the importance of self-manage-
ment in COPD clinical care and prevention of hospitalisation (GOLD,
2019). However, older people with COPD or other chronic illnesses
engage in poorer self-management activities than younger people
(Gallagher, Donoghue, Chenoweth, & Stein-Parbury, 2008). Declines
in their physical and cognitive abilities along with an increase in the
probability of comorbid diseases might make it difficult for older
people to maintain self-management. Therefore, patients require
continuing support by healthcare professionals and additional edu-
cation about the benefits of self-management in order to begin and
continue these activities.
Self-management interventions are a core component of caring
for patients with COPD (GOLD, 2019), and previous studies have
provided evidence of their utility. For example, nurse-led self-man-
agement interventions (which included two inpatient sessions and
one outpatient session) have been found to improve patients' med-
ication and exercise adherence (Korpershoek et al., 2016; Song,
Yong, & Hur, 2014). According to a systematic review by Zwerink
et al. (2014), self-management interventions have also been found to
affect health-related quality of life (HRQOL), reduce the incidence of
hospitalisation for exacerbations, and improve dyspnoea. However,
the efficacy of actual clinical practices in improving patients' adher-
ence to self-management activities has not yet been examined. The
duration, frequency and content of self-management interventions
vary by the type of healthcare service utilised. Social cognitive the-
ory (Kelder, Hoelscher, & Perry, 2015) asserts that human behaviour
has a reciprocal relationship with not only personal cognitive factors
(e.g., knowledge) and behavioural factors (e.g., self-efficacy) but also
with environmental factors (e.g., access to services). Therefore, we
assumed that different interventions in different medical settings
What does this research add to existing knowledge
in gerontology?
• The current study found that outpatient rehabilitation
and home care services were more effective than out-
patient clinics only with regard to helping older people
with COPD practice self-management activities such as
strategies to minimise dyspnoea and home exercise.
What are the implications of this new knowledge
for nursing care with older people?
• The results suggest that we need to consider strategies
to provide effective self-management intervention in
each healthcare service setting according to the unique
characteristics of each setting.
How could the findings be used to influence policy
or practice or research or education?
• To provide effective self-management intervention in
the outpatient setting, outpatient rehabilitation re-
sources should be expanded.
• To enhance the effectiveness of home care rehabilita-
tion, a standardised and comprehensive educational
programme should be developed and disseminated.
• Short-duration, low-frequency self-management inter-
ventions are needed in outpatient clinics.
might have varied effects on the practice of self-management
activities.
In Japan, the national healthcare insurance system covers all
citizens and enables them to access medical services at relatively
low costs. Healthcare services are priced at fixed rates, 10%–30%
of which is paid by the service user. In addition, long-term health-
care services are provided for individuals aged 65 years or older
with a disability or 40 years or over with an age-related disease
KITAMURA et al.
and priced at fixed rates, 10%–30% of which is paid by the service
user.
The main healthcare facilities providing self-management in-
terventions for older patients with COPD are outpatient clinics
(OC), outpatient rehabilitation centres (OR) and home care (HC)
services (Morikawa, 2014), which are covered by the national
healthcare or long-term healthcare insurance systems. Each set-
ting provides different self-management interventions in terms
of main service providers, main content, duration and frequency.
Patients generally undergo medical treatment and self-manage-
ment interventions in OC, where physicians are the main service
providers and in general simply inform patients about the basic
points of self-management, such as the need to quit smoking and
maintain medication adherence. In OC, the duration of self-man-
agement interventions (5–10 min) is shorter and the frequency
(once every 1–3 months) is lower than in OR and HC. Patients may
choose to engage in OR and HC services, in addition to OC, if their
primary physician prescribes them. Patients receive OR services
mainly from physical therapists who provide self-management
interventions including breathing techniques and exercise train-
ing. The duration of the interventions is about 40–60 min, and
the frequency varies but is generally about 4–8 times per month.
However, there are relatively few OR centres; in addition, the pa-
tient's activities of daily living (ADL) level may make it difficult
for him or her to go to an OR centre. In such cases, some patients
with COPD may receive self-management interventions through
HC, including home rehabilitation or home care nursing services.
Physical therapists or Registered Nurses are the main providers of
HC. Although they provide self-management interventions similar
to those in OC centres, such as breathing techniques and exercise
training, the visits often have a different focus and can include
regular physical assessments, ADL assistance or medication man-
agement. This is because older people who use HC services often
have lower physical and functional abilities than those who use OC
and OR services. The duration of self-management interventions
within HC is about 30–60 min, and the frequency varies but is
usually about 4–8 times per month.
While self-management activities are based on each patient's
physical and cognitive conditions, differences in self-management
interventions between settings may also have an effect. As a result,
self-management activities by patients, along with patient's physical
and cognitive conditions, may vary between healthcare settings. We
aimed to evaluate self-management activities in detail and to identify
effective approaches to improve the practice of self-management
activities among patients with COPD across different healthcare
settings in Japan. Therefore, in this study, we compared self-man-
agement activities by older people with COPD across three types
of healthcare settings: OC, OR and HC. Referring to previous stud-
ies (Disler, Gallagher, & Davidson, 2012; Zwerink et al., 2014), we
defined self-management activities as appropriate activities within
the context of persons' lives that are needed for the management of
their COPD-related symptoms, such as dyspnoea, and for maintain-
ing their mental and physical health status.
| 3 of 13
2 | M E TH O DS
2.1 | Study design, setting and data collection
We conducted a cross-sectional survey in hospitals and home care
settings, as well as a medical chart review of older patients with
COPD. This study sampled several facilities that each provided a va-
riety of OC, OR and HC services and participants were then divided
into OC, OR and HC groups based on their questionnaire responses
(rather than from which facility they were recruited). Specifically,
opportunity sampling was used to recruit participants from four
settings: one respiratory outpatient clinic of a university hospital in
Tokyo, one small internal medicine clinic in Tokyo, one respiratory
rehabilitation centre attached to a general hospital in Tokyo and 15
home care nursing agencies in Tokyo and its suburbs. Eligibility crite-
ria were (a) diagnosed with COPD, (b) aged 65 years or over, (c) able
to understand Japanese and (d) determined by attending staff to
have the physical and cognitive abilities required to complete a 40-
min survey. Patients who received chemotherapy or radiotherapy
for cancer were excluded. Subjects were diverse in terms of duration
of service use and time since diagnosis.
Three investigators—the first author and two graduate students
who were Registered Nurses and had received a lecture on data col-
lection by the first author—collected data from August to December
2017. In hospital settings, attending staff (physicians and physical
therapists) introduced the study to eligible patients following their
appointments. If the patient wished to participate, the staff intro-
duced the investigators to them. Patients who wished to partici-
pate and provided written informed consent then completed the
questionnaire by themselves in a private space at the hospital. In
HC settings, attending staff (physicians and nurses) provided eligible
patients with a document about the study. Patients who wished to
participate then provided written informed consent. The investiga-
tors visited participants' homes for data collection, and participants
completed the questionnaires by themselves. In both settings, if the
participant needed help to complete the questionnaire, the investi-
gator read the questions aloud or provided support with writing. In
addition to the survey, we collected participants' medical data from
their medical records.
The investigators explained the study using written documents
that described the aims and procedures, voluntary nature of partic-
ipation and anonymity of responses. Participants were free to with-
draw at any time. All participants provided written informed consent.
The ethics committee of the University of Tokyo (No. 11586-[1]), and
two other hospitals conducting the surveys approved this study.
2.2 | Measures
Data included information about self-management activities and
participants' characteristics such as types of healthcare services
utilised, demographics and illness-related characteristics that pre-
vious studies had identified as being related to self-management
4 of 13 | KITAMURA et al.
activities (Disler et al., 2012; Kosteli et al., 2017). Five experts (two
pulmonologists, one certified nurse specialised in chronic respira-
tory diseases, and two HC nurses) approved the content validity of
the questionnaire.
2.2.1 | Self-management activities
Referring to the GOLD (2019) guidelines and previous studies
(Chen, Chen, Lee, Cho, & Weng, 2008; Imado, Ikeda, & Matsuo,
2010), we asked about three types of self-management activities in
the questionnaire: (i) strategies to minimise dyspnoea, (ii) appropri-
ate activities to maintain physical and mental health status and (iii)
communication with healthcare professionals or family members
(Table 2).
Almost all items were rated on a five-point Likert scale ranging
from 1 (never) to 5 (always). Exercise (No. [ii] 5, 6, 7) was rated on a
five-point Likert scale: 1 (none), 2 (once to twice a month), 3 (once
a week), 4 (two to three times a week) and 5 (more than four times
a week). For the inhaler technique (No. (ii) 8), we asked about the
four steps of inhalation: breathing out, breathing in, holding breath
and gargling; the last one was only asked of steroid inhalant users.
Dichotomous variables were used for questions about inhaler tech-
niques (not correct vs. all correct; No. [ii] 8), smoking (smoke vs. have
never smoked or quit smoking; No. [ii] 10) and action plans for exac-
erbations (no vs. yes; No. [iii] 8).
Questions about the following specific treatments or conditions
were only asked to those who had used/experienced them: home oxy-
gen therapy (HOT; No. [i] 6, 7), non-invasive positive pressure ventila-
tion (NPPV; No. [i] 8), sputum (No. [i] 9), breathlessness while eating (No.
[i] 10), inhalation therapy (No. [ii] 8) and exacerbations (No. [iii] 6, 7, 8).
2.2.2 | Types of healthcare services utilised
In the questionnaire, we asked about the utilisation of three types of
healthcare services (OC, OR or HC) as well as the frequency and du-
ration of services used. After this, we divided the participants into
three groups based on their responses. If the participant had started
services 1 week or less prior to the survey or had utilised both OR
and HC services, we placed the participant into none of the three
groups. If the participant had utilised both OR and OC services, we
placed the participant into the OR group because OR is an additional
service of OC. Similarly, if the participant had utilised both HC and
OC services, we placed the participant into the HC group because
HC is an additional service of OC.
2.2.3 | Demographic characteristics
In the questionnaire, demographic data were collected regarding
age, sex, work status, educational status, living status (living alone or
with others), body mass index and smoking history.
2.2.4 | Illness-related characteristics
To examine disease severity and physical status, we extracted data
from patients' medical charts about the time since diagnosis, stage
of COPD, degree of dyspnoea, HOT, NPPV, number of previous hos-
pitalisations for exacerbations (both the total and yearly counts), co-
morbidities and care needs level within the Japanese long-term care
insurance system (not applicable; support need 1–2 to care need 1–2:
care need 3–5). We also asked about HRQOL in the questionnaire.
The stage of COPD was classified based on the GOLD (2019) cri-
teria and categorised from Stage I (mild) to Stage IV (very severe).
We asked about the degree of breathlessness during daily activities,
using the modified Medical Research Council (mMRC) Dyspnoea
Scale (Bestall et al., 1999; GOLD, 2019). This scale consists of five
statements about perceived breathlessness, from among which re-
spondents chose one statement from grade 0 (I only get breathless
with strenuous exercise) to grade 4 (I am too breathless to leave the
house, or I am breathless when dressing or undressing). HRQOL was
assessed by the Japanese COPD-specific version of the St. George's
Respiratory Questionnaire, a reliable and valid instrument used
to measure the self-reported quality of life in patients with COPD
(Meguro, Barley, Spencer, & Jones, 2007). The scores range from 0%
(no impairment) to 100% (maximum impairment).
2.3 | Data analyses
Prior to the detailed analysis, we recoded responses for self-manage-
ment activities as dichotomous variables considering clinical signifi-
cance: 1–3 vs. 4–5. However, data collected on influenza vaccination
(No. [ii] 4), walking (No. [ii] 7), medication adherence (No. [ii] 11) and
regular medical appointments (No. [ii] 14) were analysed as 1–4 vs. 5
because of the critical nature of these activities (GOLD, 2019).
Firstly, we examined the data using descriptive statistics.
Secondly, we compared participants' characteristics among the three
groups (OC, OR and HC) using the Kruskal–Wallis test, chi-square test
or Fisher's exact test. Thirdly, we compared the self-management ac-
tivities as outcome variables among the three groups using univariate
logistic regression analyses, except for some items with a high ceiling
effect (when >80% of participants answered either 4 or 5) or a high
frequency of missing responses (>30% of participants had provided
missing or non-applicable responses). Finally, we conducted multiple
logistic regression analyses to examine the association between the
types of healthcare services utilised and self-management activities,
adjusting for the degree of breathlessness and age, which we chose
as representative variables of disease severity because of the limited
sample size (Gallagher et al., 2008; Imado et al., 2010). In the multiple
logistic regression analyses, we chose outcome variables that were
significantly related to service type in the univariate logistic regres-
sion analyses. We also performed stratified analysis according to the
degree of breathlessness (mMRC 0–1 vs. 2–4) and examined the asso-
ciation between self-management activities and types of healthcare
services utilised using Fisher's exact test.
KITAMURA et al. | 5 of 13

F I G U R E 1 Flow chart of participants

[Recruited] Assessed for eligibility: N = 89
in this study. HC, home care rehabilitation
or nursing; OC, outpatient clinic; OR, One respiratory OC of a university hospital

outpatient rehabilitation One respiratory rehabilitation center attached to a general hospital in Tokyo
One small internal medicine clinic
Fifteen HC nursing agencies in Tokyo and Tokyo metropolitan area suburbs

Excluded: n = 8
• Declined to participate: n = 8

[Participated] n = 81 (response rate: 91%)

[Analyzed] n = 81 (total valid response rate: 91%)

OC group: n = 20
OR group: n = 31
HC group: n = 25
Others: Belong to none of the groups: n = 5
(e.g.) using both OR and HC

We conducted all analyses using spss Statistics for Macintosh,
version 25.0.
3 | R E S U LT S
3.1 | Participants' characteristics by healthcare
service groups
Figure 1 shows a flow chart of study participants during trial phases.
Altogether, we analysed the data of 81 participants (total valid re-
sponse rate: 91%). Participants' characteristics are shown in Table 1.
The mean age of the participants was 78.2 years, and 88% were male.
The average service provision for each group was approximately
10–15 min once every 2–3 months for OC, 40–60 min twice a week
to once a month for OR and 30–60 min twice a week to once a
month for HC. The median number of months of intervention was
10 for the OR group and 26 for the HC group.
A number of patient characteristics significantly differed be-
tween the three groups, including age, working status, body mass
index, smoking history and all illness-related characteristics (except
for the number of hospitalisations for exacerbations within 365 days
and comorbidities). The most severe conditions and lowest HRQOL
were experienced by those in the HC group, followed by those in the
OR and OC groups.
6, 7, 8), the proportions of those who practiced other strategies (No.
[i] 1, 2, 3, 4, 5, 9, 10) were about half. Regarding appropriate activi-
ties to maintain physical and mental health status, more than 80%
of the participants effectively practiced some of the basic self-man-
agement activities such as smoking cessation (No. [ii] 10), therapy
adherence (No. [ii] 11), healthy diet (No. [ii] 12, 13) and regular medi-
cal consultation (No. [ii] 14). The rates were lower for infection pre-
vention (No. [ii] 3,4), exercise (No. [ii] 5,6,7) and inhaler techniques
(No. [ii] 8). Regarding communication with healthcare professionals
or family members, approximately half of the participants practiced
the items other than those about exacerbations (No. [iii] 1–5).
3.3 | Association between self-management
activities and types of healthcare services utilised
(univariate logistic regression analyses)
In univariate logistic regression analyses, some self-management
activities were more frequently reported by participants in the OR
and/or HC groups compared with those in the OC group (Table 2).
Although we could not use logistic regression analyses for “practic-
ing pursed-lip breathing” because no participants in the OC group
reported practicing it, the rates of those who practiced were rela-
tively high in the OR and HC groups (OC: 0%, OR: 81%, HC: 48%).

3.4 | Association between self-management

3.2 | Self-management activities
Table 2 shows the self-management activities by each group. In total,
for strategies to minimise dyspnoea, even though more than 80% of
the participants reported using HOT or NPPV appropriately (No. [i]
activities and types of healthcare services utilised
(multivariate analyses)
We conducted multiple logistic regression analyses with the self-
management activities that were found to be significant in bivariate
6 of 13 | KITAMURA et al.

TA B L E 1 Participants' characteristics (N = 81)

Types of healthcare services utilised

All (N = 81)c OC (n = 20) OR (n = 31) HC (n = 25)

n (%) n (%) n (%) n (%)

Mean ± SD, or Mean ± SD, or Mean ± SD, or Mean ± SD, or

median with median with median with median with
(interquartile (interquartile (interquartile (interquartile
range) range) range) range) p Value

Demographic characteristics
Age (years) 78.2 ± 6.6 76.1 ± 5.3 76.8 ± 5.0 81.1 ± 8.3 .041a
[range] [65–103] [67–84] [67–87] [65–103]
Sex (men) 71 (88) 18 (90) 29 (94) 19 (76) .14b
Work status (working) 14 (17) 8 (40) 5 (16) 1 (4) .009b
Educational status (≥13 years) 34 (43) 8 (40) 13 (42) 10 (42) >.99b
Living status
Living alone 18 (22) 2 (10) 6 (19) 9 (36) .12b
Living with others 63 (78) 18 (90) 25 (81) 16 (64)
Body mass index 21.6 ± 3.7 23.2 ± 4.0 21.8 ± 3.3 20.2 ± 3.7 .015a
[range] [14.5–33.3] [15.4–28.6] [16.6–29.0] [14.5–33.3]
Smoking history 76 (94) 20 (100) 31 (100) 20 (80) .004b
Illness-related characteristics
Time since diagnosis (months) 58 (30–100) 59 (30–84) 48 (24–78) 84 (53–132) .039a
Stages of COPDd
I (mild) 7 (12) 3 (15) 4 (13) 0 (0) .001a
II (moderate) 20 (34) 13 (65) 6 (20) 0 (0)
III (severe) 24 (41) 4 (20) 15 (50) 2 (40)
IV (very severe) 8 (14) 0 (0) 5 (17) 3 (60)
mMRC
0 (none) 7 (9) 3 (15) 4 (13) 0 (0) <.001a
1 (mild) 16 (20) 6 (30) 7 (23) 3 (13)
2 (moderate) 23 (29) 9 (45) 8 (26) 5 (22)
3 (severe) 19 (24) 2 (10) 9 (29) 5 (22)
4 (very severe) 14 (18) 0 (0) 3 (10) 10 (44)
Home oxygen therapy 32 (40) 2 (10) 5 (16) 23 (92) <.001b
Non-invasive positive pressure ventilation 6 (7) 0 (0) 0 (0) 6 (24) <.001b
Total number of hospitalisations for COPD exacerbations
Never 40 (49) 15 (75) 19 (61) 3 (12) <.001b
More than once 41 (51) 5 (25) 12 (39) 22 (88)
Number of hospitalisations for COPD exacerbations within 365 days
Never 63 (78) 19 (95) 24 (77) 17 (68) .069b
More than once 18 (22) 1 (5) 7 (23) 8 (32)
Comorbidities
Cardiovascular disease 30 (38) 9 (45) 10 (32) 8 (33) .62b
Diabetes mellitus 15 (19) 6 (30) 5 (16) 3 (13) .36b
Dementia 3 (4) 2 (10) 0 (0) 1 (4) .18b
Orthopaedic diseases 15 (19) 3 (15) 7 (23) 4 (16) .80 b
Asthma 12 (15) 3 (15) 6 (19) 3 (12) .92b

(Continues)
KITAMURA et al. | 7 of 13

TA B L E 1 (Continued)

Types of healthcare services utilised

All (N = 81)c OC (n = 20) OR (n = 31) HC (n = 25)

n (%) n (%) n (%) n (%)

Mean ± SD, or Mean ± SD, or Mean ± SD, or Mean ± SD, or

median with median with median with median with
(interquartile (interquartile (interquartile (interquartile
range) range) range) range) p Value

Care needs level

No application 44 (56) 15 (75) 25 (86) 2 (8) <.001a
Support need 1–Care need 2 31 (39) 5 (25) 4 (14) 19 (76)
Care need 3–Care need 5 4 (5) 0 (0) 0 (0) 4 (16)
SGRQ-Ce (total score) 43.3 ± 20.9 27.6 ± 16.8 43.4 ± 19.2 55.2 ± 19.4 <.001a
[range] [5.1–89.7] [5.1–71.3] [7.3–78.2] [16.5–89.7]

Note: Missing data were excluded from this analysis, and percentages for each item were calculated after excluding missing values. Bold values
mean that p value < .05.
Abbreviations: HC, home care rehabilitation or nursing; mMRC, modified Medical Research Council Dyspnoea Scale; OC, outpatient clinic; OR,
outpatient rehabilitation.
a
Kruskal–Wallis test.
b
Chi-square test or Fisher's exact test.
c
Of 81, five participants did not belong to any group (OC, OR, HC) because they started each service within 1 week or utilised both OR and HC.
d
Severity of COPD: Classified based on the Global Initiative for Chronic Obstructive Lung Disease guidelines.
e
SGRQ-C, COPD-specific version of the St. George Respiratory Questionnaire. Higher scores indicate lower quality of life.

analyses (Table 3). Even after adjusting for dyspnoea level and age,
those in the OR and/or HC groups reported significantly higher self-
management practice compared with those in the OC group for “mov-
ing body corresponding to breathing” (OR: adjusted odds ratio [AOR],
6.71; 95% confidence interval [CI], 1.82–24.69) (HC: AOR, 6.98; 95%
CI, 1.42–34.33), “trying not to move quickly” (OR: AOR, 5.46; 95%
CI, 1.19–25.10), “avoiding suffocating movements” (HC: AOR, 7.37;
95% CI, 1.40–38.73), “getting an influenza vaccination” (OR: AOR,
8.12; 95% CI, 1.82–36.14) (HC: AOR, 7.81; 95% CI, 1.37–44.68),
“stretching exercise” (OR: AOR, 6.42; 95% CI, 1.70–24.18) (HC: AOR,
16.76; 95% CI, 2.56–109.89), “muscle training” (OR: AOR, 8.49; 95%
CI, 2.14–33.64) (HC: AOR, 9.73; 95% CI, 1.85–51.27) and “discussing
lifestyle goals with healthcare professionals” (HC: AOR, 5.75; 95% CI,
1.12–29.54).
When stratified by the degree of breathlessness, among partici-
pants with no to mild breathlessness (mMRC 0–1), there were signifi-
cant differences across the three groups in only the items “practicing
pursed-lip breathing” (OC: 0%, OR: 64%, HC: 33%, p = .005) and
“influenza vaccination” (OC: 29%, OR: 88%, HC: 100%, p = .043).
Conversely, among participants with moderate to very severe
breathlessness (mMRC 2–4), there were many significant differences
between the three groups, such as “practicing pursed-lip breathing”
(OC: 0%, OR: 90%, HC: 55%, p < .001), “trying not to move quickly”
(OC: 22%, OR: 75%, HC: 80%, p = .01), “keeping the room organised”
(OC: 18%, OR: 50%, HC: 70%, p = .02), “avoiding suffocating move-
ments” (OC: 27%, OR: 45%, HC: 75%, p = .03), “stretching” (OC: 27%,
OR: 75%, HC: 95%, p < .001), “muscle training” (OC: 18%, OR: 80%,
HC: 85%, p < .001), “going for a walk” (OC: 55%, OR: 50%, HC: 10%,
p = .02) and “discussing lifestyle goals with healthcare professionals”
(OC: 9%, OR: 55%, HC: 70%, p = .004).
4 | D I S CU S S I O N
In this study, after adjusting for breathlessness and age, we found
that more participants with COPD using OR or HC services prac-
ticed some self-management activities (such as breathing techniques
and home exercise) than those using only OC services. To the best
of our knowledge, this is the first study to compare the practices
of specific self-management activities among older patients with
COPD, who receive services in different types of healthcare settings
where different healthcare professionals provide self-management
interventions (physicians in OC, physical therapists in OR and nurses
or physical therapists in HC). A variety of self-management activi-
ties were evaluated using a comprehensive set of self-management-
related items. The findings are useful when considering appropriate
approaches for improving self-management interventions in the dif-
ferent healthcare settings currently available in Japan.
This study revealed that most participants (approximately 80%
or more) practiced some basic self-management activities regardless
of healthcare setting, such as smoking cessation and medication ad-
herence. Previous studies have reported that older patients regularly
seeing a physician had sufficient information and good compliance
with medication and smoking cessation (Jones, Hyland, Hanney, &
Erwin, 2004; Sandelowsky, Krakau, Modin, Ställberg, & Nager, 2019;
Ueki et al., 2011). This seems to suggest that, together with the results
TA B L E 2 Association between self-management activities and types of healthcare services utilised in univariate logistic regression analyses
8 of 13

All (N = 81)a OC (n = 20) OR (n = 31) HC (n = 25) OR (Reference: OC) HC (Reference: OC)

|

Na n (%) n (%) n (%) n (%) AOR [95% CI–UL] AOR [95% CI–UL]

(i) Strategies to minimise dyspnoea

1. When I breathe with difficulty during the motion, I practice 39 (48) 0 (0) 25 (81) 12 (48) 6.30 [1.78–22.24]** 4.50 [1.24–16.35]*
pursed-lip breathing.
2. I move body corresponding to breathing. 42 (52) 5 (25) 21 (68) 15 (60) 6.92 [1.66–28.94]** 10.62 [2.38–47.50]**
3. I am trying not to move quickly. 40 (51) 3 (17) 18 (58) 17 (68) 3.58 [0.86–14.87] 8.50 [1.96–36.79]**
4. I keep my room organised or arrange the furniture to move 33 (41) 3 (15) 12 (39) 15 (60) 3.12 [0.75–13.04] 10.07 [2.31–44.00]**
efficiently without effort.
5. I am trying to avoid suffocating movements. 32 (40) 3 (15) 11 (35) 16 (64)
6. I use home oxygen therapy appropriately at rest. A 28 (90) 1 (50) 4 (80) 21 (96)
7. I use home oxygen therapy appropriately during exercise. A 32 24 (75) 0 (0) 4 (60) 19 (83)
8. I use non-invasive positive pressure ventilation A 6 6 (100) — — 6 (100)
appropriately.
9. I am trying to cough out sputum efficiently. B 54 24 (44) 3 (23) 10 (48) 10 (63)
10. I feel breathless while eating, so I try to have several small B 7 1 (14) — 0 (0) 1 (25)
meals a day
(ii) Appropriate behaviours to maintain physical and mental health status
1. I record my physical condition, symptoms, or self- 41 (51) 7 (35) 19 (61) 14 (56) 2.94 [0.91–9.46] 2.36 [0.70–7.94]
management activities.
2. I am trying not to build up stress. 41 (52) 8 (40) 17 (55) 15 (65) 1.82 [0.58–5.70] 2.81 [0.81–9.71]
3. I practice gargling and handwashing when I come back 51 (63) 14 (70) 18 (58) 16 (64) 0.59 [0.18–1.96] 0.76 [0.22–2.68]
home or before eating.
4. I get an influenza vaccination in the winter. 53 (74) 7 (39) 21 (84) 20 (83) 8.25 [1.98–34.43]** 7.86 [1.88–32.90]**
5. I practice stretching exercises. 50 (62) 5 (25) 22 (71) 21 (84) 7.33 [2.05–26.25]** 15.75 [3.61–68.66]***
6. I practice muscle training. 47 (58) 4 (20) 22 (71) 19 (76) 9.78 [2.55–37.43]*** 12.67 [3.03–52.89]***
7. I go for a walk. 38 (48) 12 (67) 20 (65) 5 (20) 0.91 [0.27–3.10] 0.13 [0.03–0.50]**
8. I utilise effective inhaler techniques. 33 (45) 7 (37) 17 (57) 8 (32) 2.24 [0.69–7.29] 1.14 [0.31–4.16]
9. I sleep well. 63 (78) 19 (95) 24 (77) 18 (72) 0.18 [0.02–1.60] 0.14 [0.02–1.21]
10. I have quit smoking or never smoked. B 74 (91) 16 (80) 29 (94) 25 (100)
11. I adhere to medication therapy. B 65 (80) 15 (75) 24 (77) 22 (88)
12. I eat healthy food adequately. B 67 (84) 15 (75) 28 (90) 19 (79)
13. I take sufficient protein. B 72 (90) 18 (90) 30 (97) 19 (79)
14. I see a doctor regularly. B 78 (99) 20 (100) 30 (97) 23 (100)
KITAMURA et al.

(Continues)
 KITAMURA et al.

TA B L E 2 (Continued)

All (N = 81)a OC (n = 20) OR (n = 31) HC (n = 25) OR (Reference: OC) HC (Reference: OC)

Na n (%) n (%) n (%) n (%) AOR [95% CI–UL] AOR [95% CI–UL]

15. I listen to and check my medical data when I see a doctor. B 63 (89) 19 (95) 26 (84) 14 (93)
16. I do not overdo it when I am sick. B 74 (96) 19 (95) 28 (97) 23 (96)
(iii) Communication with healthcare professionals or family members
1. I discuss my concerns or questions with healthcare 47 (59) 11 (55) 18 (58) 17 (71) 1.13 [0.36–3.52] 1.99 [0.57–6.90]
professionals.
2. I discuss my lifestyle goals with healthcare professionals. 34 (43) 4 (20) 14 (45) 16 (67) 3.29 [0.89–12.14] 8.00 [2.00–31.99]**
3. I discuss my lifestyle goals with my family. 26 (33) 6 (32) 10 (32) 10 (42) 1.03 [0.30–3.52] 1.55 [0.44–5.47]
4. I discuss my thoughts regarding treatment or the place I 35 (44) 6 (30) 14 (45) 14 (58) 1.92 [0.58–6.31] 3.27 [0.93–11.45]
want to spend with healthcare professionals.
5. I discuss my thoughts regarding treatment or the place I 30 (38) 9 (45) 11 (35) 9 (38) 0.67 [0.21–2.12] 0.73 [0.22–2.45]
want to spend with my family.
6. I report to healthcare professionals when I experience acute B 36 31 (86) 5 (100) 13 (81) 12 (92)
worsening of respiratory symptoms.
7. I think back on the reasons for exacerbations with B 37 19 (51) 2 (40) 7 (44) 10 (71)
healthcare professionals.
8. I have action plans for exacerbations, as instructed by the B 32 6 (8) 1 (25) 0 (0) 5 (42)
doctor.

Note: Missing data were excluded from these analyses, and percentages for each item were calculated after excluding missing values. A: As more than 80% of the participants answered either “4: often
do” or “5: always do,” we did not conduct logistic regression analyses. B: As more than 30% of the participants did not respond, we did not conduct logistic regression analyses.
Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; HC, home care rehabilitation or nursing; LL, lower limit; N/A. not applicable; OC, outpatient clinic; OR, outpatient rehabilitation; UL,
upper limit.
a
The number of respondents for each item is shown and used for percentage calculation of all participants.
*p < .05, **p < .01, ***p < .001.
|
9 of 13
 10 of 13
|

TA B L E 3 Association between self-management activities and types of healthcare services utilised: Comparison with the OC group in multiple logistic regression analyses

(i) Strategies to minimise dyspnoea

2. Moving body corresponding to 5. Avoiding suffocating movements

breathing (n = 74) 3. Trying not to move quickly (n = 74) 4. Keeping the room organised (n = 74) (n = 74)

AOR [95% CI–UL] p AOR [95% CI–UL] p AOR [95% CI–UL] p AOR [95% CI–UL] p

mMRC 1.04 [0.66–1.66] .86 2.48 [1.41–4.36] .002 1.80 [1.09–2.98] .022 1.53 [0.94–2.49] .091
age 0.94 [0.86–1.03] .19 1.02 [0.92–1.13] .75 1.01 [0.92–1.11] .83 1.01 [0.92–1.11] .84
OR (reference: OC) 6.71 [1.82–24.69] .004 5.46 [1.19–25.10] .029 2.74 [0.63–11.98] .18 2.54 [0.58–11.00] .21
HC (reference: OC) 6.98 [1.42–34.33] .017 5.11 [0.90–29.00] .065 5.01 [0.96–26.26] .056 7.37 [1.40–38.73] .018

(ii) Appropriate activities to maintain physical and mental health status

4. Getting an influenza vaccination (n = 65) 5. Practicing stretching exercises (n = 74) 6. Practicing muscle training (n = 74) 7. Going for a walk (n = 72)

AOR [95% CI–UL] p AOR [95% CI–UL] p AOR [95% CI–UL] p AOR [95% CI–UL] p

mMRC 1.04 [0.57–1.89] .90 0.59 [0.92–2.75] .10 1.70 [1.00–2.90] .049 0.43 [0.24–0.76] .004
age 1.08 [0.96–1.21] .20 1.10 [0.98–1.23] .12 1.02 [0.92–1.13] .69 0.99 [0.89–1.09] .82
OR (reference: OC) 8.12 [1.82–36.14] .006 6.42 [1.70–24.18] .006 8.49 [2.14–33.64] .002 1.32 [0.35–5.00] .69
HC (reference: OC) 7.81 [1.37–44.68] .021 16.76 .003 9.73 [1.85–51.27] .007 0.32 [0.07–1.57] .16
[2.56–109.89]

(iii) Communication with healthcare professionals or family members

2. Discussing lifestyle goals with healthcare professionals (n = 74）

AOR [95% CI–UL] p

mMRC 1.68 [103–2.74] .040

Age 0.92 [0.84–1.02] .10
OR (reference: OC) 2.89 [0.73–11.44] .13
HC (reference: OC) 5.75 [1.12–29.54] .036

Note: Bold values mean that p value < .05.

Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; HC, home care rehabilitation or nursing; LL, lower limit; mMRC, modified Medical Research Council Dyspnoea Scale; OC, outpatient
clinic; OR, outpatient rehabilitation; UL, upper limit.
KITAMURA et al.
KITAMURA et al.
from this study, most physicians are successful in achieving adequate
compliance among older patients with regard to smoking cessation
and pharmacotherapy from the early stage of COPD. However, the
three settings have common issues; participants across all settings
reported limited discussion with healthcare professionals about sig-
nificant topics such as future treatment options or choices of residen-
tial location that are appropriate for their treatment. Some barriers
(such as uncertainty in prognosis and poor recognition of advance
care planning; Patel, Janssen, & Curtis, 2012) might make communi-
cating hopes for treatment and life plans more difficult for patients
with COPD. As such, there is further room to consider the quality
of communication between clients and professionals in all settings.
More participants using OR or HC services were engaged in
practicing breathing techniques and home exercises than those
using only OC services. Physical therapists and nurses in OR and HC
settings provide non-pharmacological treatment like rehabilitation,
whereas physicians in OC setting mainly provide pharmacological
treatment; the differences in approach might affect participants'
self-management activities. Previous studies have found that ef-
fective self-management interventions contained contents such as
breathing techniques and home exercises, and were provided by not
only physicians but also nurses or rehabilitation staff (Moriyama,
Takeshita, Haruta, Hattori, & Ezenwaka, 2015; Zwerink et al., 2014). It
has also been said that the effects of a self-management intervention
on health status and health care utilisation result from behavioural
changes, which in turn are caused by enhancement of self-efficacy,
knowledge, and skill (Bourbeau, Nault, & Dang-Tan, 2004). Our study
suggests that multi-professional teams and comprehensive inter-
ventions provided in OR and HC settings might lead to behavioural
change by helping participants acquire the knowledge and skills for
breathing techniques and home exercises and improving their self-ef-
ficacy. Additionally, more participants in the HC group communicated
with healthcare professionals about their lifestyle goals than those
in the other two groups. Previous studies have revealed that HC
nurses improved clients' health conditions through the development
of caring relationships and goal setting (Liebel, Friedman, Watson, &
Powers, 2012). These components of intervention within may help
participants communicate with healthcare professionals regarding
their lifestyles and express their own hopes and goals with ease.
While this study has revealed the effects of both OR and HC on
self-management activities, utilisation of OR is not common in the
current healthcare system in Japan because of its limited availability
(Nishi, Zhang, Kuo, & Sharma, 2016). Therefore, it is suggested to pro-
mote home-based pulmonary rehabilitation in the HC setting, which
has had effects equivalent to hospital-based pulmonary rehabilitation
on exercise tolerance and HRQOL (Holland et al., 2016). However,
the current study also found some issues and areas in need of im-
provement in HC. Although almost all participants with less breath-
lessness reported walking regularly, few in the HC group with severe
breathlessness reported walking regularly. A previous study revealed
that a nurse-led self-management programme for patients with se-
vere COPD also improved patients' social activity levels (Moriyama
et al., 2015), and therefore, our results suggest that HC may need
| 11 of 13
to develop better intervention strategies for promoting outdoor ex-
ercise in patients with moderate to very severe breathlessness. We
should develop a systematic educational programme that draws on
the strengths of the HC setting and corrects existing problems.
Along with developing pulmonary rehabilitation programmes
in HC for patients with severe breathlessness, we should also
consider short-duration and low-frequency self-management in-
terventions in the OC setting for those with slight breathlessness.
This is due to difficulties in providing the pulmonary rehabilitation
programme in HC for all patients, and the fact that in the pres-
ent scenario, the majority of patients with COPD use OC services.
The results of this study suggest that OC settings do not provide
adequate education regarding breathing techniques and home ex-
ercises. Recently, it has been said that interventions using online
contents could improve the level of physical activity and COPD-
specific knowledge in patients with COPD (Nyberg, Tistad, &
Wadell, 2019). Therefore, in addition to the usual outpatient con-
sultations, we should also teach self-management activities from
the early stages of COPD using web-based education and other
tools such as booklets, group education sessions, and nursing out-
patient consultations.
This study had several limitations. Firstly, not all confounding
variables could be considered. Although age and degree of breath-
lessness were used as control variables—because they could be repre-
sentative variables that affect self-management activities (Gallagher
et al., 2008; Imado et al., 2010)—we could not adjust for other factors
such as history of exacerbation and use of medical equipment due
to the limited sample size. These factors may be related to previous
self-management interventions provided during inpatient stays; thus,
participants' self-management activities might also be affected by
these factors. Due to the limited sample size, we also could not con-
sider differences in service use length and frequency for each group
(OC, OR or HC). Although we excluded participants who had started
the service within a week, variations in exposure to interventions
might also have affected participants' self-management activities.
Secondly, the results may not be generalisable to all patients
with COPD, as this study was only conducted in specific medical
settings. In particular, participants in the OC group were recruited
from only one university hospital in an urban area; therefore, these
patients may have less severe COPD because they are able to access
a hospital that is not necessarily near their home. Moreover, we re-
cruited participants who regularly used certain healthcare services.
Therefore, the participants in this study may have good medical ad-
herence compared to those who do not use any health services regu-
larly. Additionally, the majority of older people were men. Therefore,
we should be careful when generalising the results of this study.
Thirdly, the self-management activities and the services (type,
duration and frequency) were measured via subjective perception
and so may not accurately reflect the truth. Future studies should
attempt to assess them in a more direct and quantifiable manner.
Finally, the cross-sectional design prevents the drawing of conclu-
sions regarding causality. A longitudinal study that examines whether
these related factors affect self-management activities is thus needed.
12 of 13 | KITAMURA et al.
5 | CO N C LU S I O N
We conducted a cross-sectional study in elderly participants with
COPD to identify their self-management activities and their associa-
tion with types of healthcare services utilised. Some self-manage-
ment activities (such as breathing techniques and home exercises)
were associated with the use of OR or HC services, an effect persist-
ing after adjusting for degree of breathlessness and age. This indi-
cates that introducing additional services, such as OR and HC, may
prove beneficial in providing education on breathing techniques and
exercises. Furthermore, we should develop short-duration and low-
frequency self-management interventions for the OC setting.
IMPLICATIONS FOR PRACTICE
• Findings suggest that we should provide additional
services such as OR and HC besides OC to older peo-
ple with COPD who are unable to practice self-man-
agement activities.
• We need to consider strategies to provide effective
self-management intervention in each healthcare ser-
vice setting according to the unique characteristics of
each setting.
C O N FL I C T O F I N T E R E S T
The authors have no conflicts of interest relevant to this paper to
declare.
AU T H O R C O N T R I B U T I O N S
Study design: SK, AI, NYM; data collection: SK, YY, HS, TH; data anal-
ysis: SK, AI, NYM; manuscript preparation: SK, AI, NYM. All authors
critically reviewed and approved the final version of the manuscript.
ORCID
Satomi Kitamura https://orcid.org/0000-0003-1452-2283
Ayumi Igarashi https://orcid.org/0000-0002-5292-8893
Takeo Horie https://orcid.org/0000-0001-9365-5804
Noriko Yamamoto-Mitani https://orcid.
org/0000-0002-1704-7011
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How to cite this article: Kitamura S, Igarashi A, Yamauchi Y,
Senjyu H, Horie T, Yamamoto-Mitani N. Self-management
activities of older people with chronic obstructive pulmonary
disease by types of healthcare services utilised: A cross-
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