Understanding Barriers to and Strategies for Medication Adherence in COPD

A Qualitative Study

Jacqueline O'Toole; Meera Krishnan; Kristin Riekert; Michelle N. Eakin


BMC Pulm Med. 2022;22(98) 

In This Article

Abstract and Introduction


Background: Medication adherence in chronic obstructive pulmonary disease (COPD) is low, though not enough is known about the factors that affect adherence in COPD. This study uses qualitative methods to understand the patient perspective on facilitators and barriers to medication adherence in COPD as well as patient-reported strategies for self-management of disease.

Methods: Semi-structured interviews were conducted with 30 individuals (n = 30). Transcripts were analyzed using iterative qualitative coding by 2 independent coders, and codes were categorized using thematic analysis.

Results: Challenges with adherence reported were gaps in understanding, forgetfulness of the patient, physician availability, cost navigation, and overcoming substance use. Most commonly, the financial burden of COPD medications caused patients to source other countries to obtain medications, rely on sample medications collected during doctors' visits, and to alter medication dosage and frequency to extend the length of a prescription. Tools and resources reported by patients to support self-management of COPD included pharmacist assistance, physician office information, and community resources. Individuals further reported that the use of logs or diaries to track medication usage, visual or temporal cues to take medications, and support from family members were helpful in promoting adherence to their COPD medication regimen.

Conclusions: Medication adherence in individuals with COPD is affected by challenges with self-management of disease and financial burden of medications. However, patients reported multiple tools and resources to support adherence. Physician recognition of these factors impacting self-management, as well as awareness of strategies to promote adherence and manage disease, may improve patient outcomes.


Chronic obstructive pulmonary disease (COPD) is a highly prevalent disease worldwide and contributes to high mortality and cost within the medical system.[1–3] Adherence to medication regimens in COPD has been notoriously low, with reports of 15–30% adherence.[4–7] Low adherence in COPD is associated with higher healthcare costs, increased hospitalizations, and worse disease control.[8] In recent years, the European Union has made adherence practices a priority in health care, particularly in reference to COPD.[3] Low adherence stems from many factors, including suboptimal communication, financial burdens, time intensive regimens, comorbid diseases, and personal factors that affect the ability to self-manage disease.[9–11]

Achieving good adherence involves a process including the initiation, implementation, and persistence of a treatment plan.[12] In COPD, this means obtaining and taking the first inhaled dose followed by obtaining and taking refills of the medication over time. To accomplish this, individuals must have the ability to understand, obtain and correctly administer medications on an appropriate schedule, which presents many challenges. One such challenge is that individuals with COPD often have comorbid diseases, resulting in a larger burden of care than managing an isolated disease.[10,13] In addition, inhaled medications tend to be expensive and with varying insurance coverage making access to maintenance of therapy challenging.[10,13] Patients taking medication for COPD are often forced to choose where to allocate financial resources each month among other medical and daily living needs.[10]

The quantity and variety of different inhaler delivery devices for COPD pose unique challenges for self-management, particularly in an aging population with dexterity and visual limitations. There are at least seven inhaler delivery devices available, meaning individuals with more than one prescribed inhaler may have more than one device to learn.[14] Despite guidelines recommending inhaler teaching, the process of prescribing inhaled therapies and ensuring proper usage among affected patients is often inconsistent and unclear.[15,16] This raises a technical challenge for patients and highlights the importance of good communication surrounding medication plans specifically with one's care team. The strength of patient-doctor interactions is pivotal for supporting adherence to inhalers.[17]

Though it is well-established that adherence in COPD is low, little is known regarding individual perspectives on these challenges and what resources and tools people with COPD view as most important to assist in adherence to COPD medication plans. Through the National Health Service in Great Britain, informative data at a population level documenting the presence of general patient experiences with COPD are available. However, exploration of such experiences and how they pertain to self-management of disease are lacking.[18] With so many factors contributing to adherence, it is important to understand what people with COPD value and experience. The goal of this study is to explore the patient perspective regarding medication adherence in COPD and gain insight to facilitators and barriers to medication adherence as well as patient-reported strategies for maintaining adherence. The patient perspective regarding medication adherence in COPD management will be informative to future efforts to target initiatives to improve adherence, a necessary step in improving COPD outcomes.