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Self-management behaviours for patients with chronic obstructive pulmonary disease: a qualitative study
Kang-Hua Chen, Mei-Ling Chen, Sheuan Lee, Hsiu-Ying Cho & Li-Chueh Weng
Accepted for publication 21 July 2008

Correspondence to K.-H. Chen: e-mail: khc@mail.cgu.edu.tw Kang-Hua Chen RN MSN Doctoral Candidate Chung Shan Medical University, Taichung, and Instructor School of Nursing, Chang Gung University, Tao-Yuan, Taiwan Mei-Ling Chen PhD RN Professor School of Nursing, Chang Gung University, Tao-Yuan, Taiwan Sheuan Lee PhD RN Professor & Dean College of Nursing, Chung Shan Medical University, Taichung, Taiwan Hsiu-Ying Cho BS Leader Respiratory Therapist Department of Respiratory Therapy, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan Li-Chueh Weng PhD RN Assistant Professor School of Nursing, Chang Gung University, Tao-Yuan, Taiwan

C H E N K . - H . , C H E N M . - L . , L E E S . , C H O H . - Y . & W E N G L . - C . ( 2 0 0 8 ) Selfmanagement behaviours for patients with chronic obstructive pulmonary disease: a qualitative study. Journal of Advanced Nursing 64(6), 595604 doi: 10.1111/j.1365-2648.2008.04821.x

Abstract
Title. Self-management behaviours for patients with chronic obstructive pulmonary disease: a qualitative study. Aim. This paper is a report of a study to explore the self-management behaviours of patients with chronic obstructive pulmonary disease (COPD). Background. Chronic obstructive pulmonary disease is a major cause of chronic morbidity and mortality throughout the world. A patient-centred perspective calls for the investigation of self-management behaviours as means to develop selfmanagement programmes and enhance quality of life for patients with COPD. Method. The participants were a convenience sample of 18 patients with COPD of various severities. Interview data were collected in the thoracic ward, outpatient department and pulmonary rehabilitation unit of a medical centre in Taiwan from November 2006 to April 2007. Findings. Participants demonstrated the ability to choose suitable disease management behaviours to prevent symptoms and complications. Five themes of disease management behaviours were identied: symptom management, activity and exercise implementation, environmental control, emotional adaptation and maintaining a healthy lifestyle. Conclusion. Participants are experts on their lives and, as such, they adopt appropriate disease control behaviours, based on their experience and knowledge, as well as integrate the illness and its symptoms into their lives. With the worldwide increase in migration, an understanding of the cultural factors that inuence patients perspectives on self-management behaviours is necessary and can contribute to the development of an evidence-based programme for disease self-management with COPD. Keywords: chronic disease, chronic obstructive pulmonary disease, interviews, qualitative study, respiratory nursing, self-management behaviour

Introduction
Chronic obstructive pulmonary disease (COPD) in adults is a major health problem. The prevalence rate of COPD is

410% and further increases in its prevalence and mortality are predicted for the coming decades (Halbert et al. 2003, Global Initiative for Chronic Obstructive Lung Disease [GOLD] 2006). Among other factors, these increases are in
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response to a longer life expectancy, coupled with an increasing number of individuals who smoke (GOLD 2006, Barnes 2007). Because many patients do not show severe airow limitations and therefore have not been diagnosed with COPD, the prevalence rate stated above underestimates the incidence (Cross 2005, GOLD 2006). The World Health Organisation projects that, by 2020, COPD will be the third leading cause of death worldwide. Chronic obstructive pulmonary disease was ranked as the 11th cause of death in Taiwan in 2000, but this statistic is also an underestimate. Moreover, according to the National Health Insurance Organisation of Taiwan (Department of Health [DOH] 2005), based on the number of outpatient, inpatient and emergency cases, as well as cost, respiratory diseases had the highest incidence among all diseases. Furthermore, with increasing age, the prevalence rate of bronchitis, emphysema and asthma also increases (DOH 2005). Finally, Taiwan has become an ageing society, with older people representing 95% of the population (DOH 2005), which also contributes to the increasing number of cases of COPD. Thus, COPD is a major personal and public health burden in Taiwan, as in other countries (GOLD 2006). Chronic obstructive pulmonary disease is considered a chronic and not fully reversible disease; thus, treatment is aimed at providing supportive care and assistance in disease self-management. The goal of treatment is not to cure the disease. Rather, it is to palliate symptoms, maintain physical functioning and prevent further disability, as well as to decrease hospital and emergency room (ER) visits and, importantly, to promote quality of life (Bourbeau et al. 2003, Monninkhof et al. 2004, Linnell 2005). The emphasis in self-management of chronic disease is on the important role of patients themselves. Knowledge and techniques learned by patients from healthcare professionals are helpful for managing disease and overcoming mental, physical and social problems. Developing a patient-centred self-management programme calls for healthcare professionals to understand what patients do to cope with diseaserelated problems.

Background
Self-management programmes have been reported to have positive effects on healthcare outcomes (Holman & Lorig 2004, Jerant et al. 2005). Specically, they have been found to promote self-efcacy, emotional status, medication adherence, quality of life, and to reduce hospital and ER visits in patients with chronic asthma, diabetes, hypertension or arthritis (Bourbeau et al. 2003, Coleman & Newton 2005, Fu et al. 2006, Swerissen et al. 2006).
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Lorig et al. (2000) and Jerant et al. (2005) have emphasized that patients can be in control of their diseases if they are given an action plan and behavioural changes to implement. As part of self-management, patients need to learn the techniques of problem-solving to make the best decisions and to evaluate their performance. Lobo (2005) noted that individuals with physiological needs require complex nursing care and called for both qualitative and quantitative studies to broaden our knowledge of the needs of these patients. The ultimate goal should be the development of evidence-based interventions to decrease morality and lower disability. Recently, a number of qualitative studies have been conducted on dyspnoea self-management, self-care issues, and the effectiveness of self-management programmes with COPD. For example, by studying two groups of patients (sarcoidosis and COPD), who were taught to actively engage in health-promoting activities for dyspnoea management, Nield (2000) identied four themes of self-management: traditional medical care, self-care wisdom, self-care action and self-care resources. Using focus group research, Cicutto et al. (2004) found that patients self-care activities mainly involved surviving COPD. If patients want to maintain their quality of life, they need to understand how to adjust, both physically and emotionally, to COPD. Additionally, to enable patients to achieve the best quality of life, healthcare professionals should use approaches that support the individual as a whole. Monninkhof et al. (2004) implemented a COPD selfmanagement programme and evaluated patients quality of life, using St. Georges Respiratory Questionnaire (SGRQ; Jones et al. 1992). Because the results showed that the programme did not statistically signicantly improve quality of life when measured by the SGRQ, the researchers then conducted a qualitative study. They interviewed 20 participants, who indicated that the self-management programme increased exercise capacity, helped them understand how to implement self-treatment, and enhanced their condence and ability to cope with the disease. Although the patients perspective indicated that the programme had positive results in these specic areas, it seems that the SGRQ was not able to detect these changes and no other instrument was available for this purpose. Cicutto and Brooks (2006) stated that healthcare professionals are in the best position to encourage patients to participate in a self-management programme. This is especially true for the Taiwanese healthcare system, in which physicians and patients do not generally work together as partners. However, based on the increasing number of patients with COPD, as well as research on the effectiveness

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of self-management programmes for diabetes, children with asthma, schizophrenia and end-stage renal disease in Taiwan (Lou et al. 2004, Tsay & Hung 2004, Chiang et al. 2005, Tsai & Chen 2006), it has become essential for Taiwanese healthcare professionals to understand disease self-management behaviours and to develop self-management programmes for COPD, as well as instruments to measure the effectiveness of such programmes.

Data collection
Data were collected from November 2006 to April 2007. The rst author conducted semi-structured, face-to-face interviews. The interview began with general questions, followed by more specic ones (Table 2). Each interview took approximately 3070 minutes and was tape-recorded. After the interviews, the tapes were transcribed by a research assistant and checked by the rst author. Data collection was done concurrently with data analysis. Data collection was discontinued when theme saturation was achieved during the last two interviews (Strauss & Corbin 1998).

The study
Aim
The aim of this study was to explore the self-management behaviours of patients with COPD as a means to understand how patients manage their disease.

Ethical considerations
The appropriate Institutional Review Board approved the study. The interviewer presented the purpose of the study and obtained signed consent before interviewing and taperecording. Had there been any situation or question that made a participant uncomfortable, the interview would have been stopped immediately; however, such a situation did not arise. To ensure condentiality, the tapes were transcribed without the names of participants.

Design
A qualitative, descriptive design was adopted. In-depth interviews were used to collect the data.

Participants and setting

A convenience sample of 18 men who had had COPD for at least 1 year and who spoke Mandarin or Taiwanese were invited to participate in the study. To better understand the behaviours of patients under different conditions, participants were drawn from different settings: including a thoracic ward, outpatient department, and the respiratory therapy room in a medical centre in Northern Taiwan. Sample size was determined by theme saturation (Strauss & Corbin 1998). The age range of participants was 5581 years (mean = 7406). According to the GOLD (2006) severity classication of COPD (Table 1), three participants were in the mild stage, ve were in the moderate stage, eight were in the severe stage and one was in the very severe stage. One patient who missed a spirometry examination could not be classied.

Data analysis
Miles and Hubermans (1994) three-step method was used to analyse the data. The rst step was data reduction, in which the data were manually coded. After reading the interview transcripts several times, the researcher identied signicant
Table 2 Interview questions General questions 1. Could you briey describe when your lung disease was diagnosed? 2. How did the doctor explain your disease and what are the symptoms when you have about? Specic questions 1. How do you care for yourself when symptoms occur? 2. What effect does COPD have on you when you exercise and perform daily activities? 3. How does COPD inuence your physical status and emotions? 4. What effects do COPD have on your relationship with family and friends? 5. How do your family or friends help you to handle your problems in daily life? 6. How do you change your environment after COPD was diagnosed as to safeguard your health? 7. Which methods do you use in daily life to safeguard your health? 8. Is there anything else you would like to tell me about your experience while handling this disease in your daily life? COPD, chronic obstructive pulmonary disease. 597

Table 1 Spirometric classication of severity of chronic obstructive pulmonary disease Severity Mild Moderate Severe Very severe Characterized by airow limitation FEV1/FVC FEV1/FVC FEV1/FVC FEV1/FVC < < < < 070, 070, 070, 070, FEV1 80% predicted 50% FEV1 < 80% predicted 30% FEV1 < 50% predicted FEV1 < 30% predicted

FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity.

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statements, line by line, without making any assumptions, and then compared transcripts between participants to determine similarities and differences in the codes. The second step was data display, in which diagrams were developed to display relationships between codes, and then pattern coding was done. This involved sorting the codes according to areas of disease self-management behaviours (e.g. activity, physiological, psychosocial and environment). The third step was conclusion drawing, in which themes and sub-themes were identied and named to describe patients self-management behaviours.

Table 3 Themes and sub-themes in the data Theme Symptom management Sub-theme Reducing activity and resting Selecting medications Breathing control and effective coughing Emergency approaches Following rehabilitation instructions Lowering the speed and shortening the distance Choosing sedentary activities and alternative methods Temperature and humidity control Rearranging furniture Choosing a certain environment Positive thinking Accepting their fate Getting used to the symptoms Exercising and taking medication on a regular basis Complying with traditional Chinese care taking measures Quitting smoking

Activity and exercise implementation

Environmental control

Rigour
We followed Lincoln and Gubas (1985) guidelines for ensuring trustworthiness, which was established through consistency, prolonged engagement, peer debrieng, dependability and conrmability. Taped interviews and written transcripts were examined by two researchers to ensure consistency. Patients with COPD who gave important insights were interviewed a second time, which is called prolonged engagement. The rst author and an experienced lecturer, both of whom were experienced in conducting qualitative studies, analysed the transcripts and discussed the themes and sub-themes (peer debrieng) until consensus was achieved, thus establishing dependability. Finally, conrmability was ensured by two participants, who examined and validated the researchers interpretation of the nding.
Emotional adaptation

Maintaining a healthy lifestyle

We know that if I walk fast or climb stairs, I will have a sense of breathlessness. If I climb to the third or fourth oor, I will stop for a rest, for 10 or 30 to 40 seconds, and climb again.

Findings
Self-management behaviours, from the participants perspective, were those that prevented a bout or exacerbation of lung disease. Further, they chose the behaviours that suited them and that helped them maintain stable living conditions. Our ndings showed that self-management behaviours of patients with COPD could be understood through ve themes and 16 sub-themes, as presented in Table 3.

When experiencing symptoms, some participants chose inhalation of an anti-cholinergic agent, as well as a b2-agonist bronchodilator, following the prescription of healthcare professionals:
I seldom use it [fenoterol] unless it is serious or when I exercise. I use it when it is necessary. It works quite well when you have breathlessness. If I have only mild breathlessness, I use it [ipratropium].

One participant, whose condition was severe and who was hospitalized many times with acute exacerbation, stated:
One time, I did not know what happened. My medicine did not

Symptom management
Dyspnoea, cough and sputum production are common symptoms of COPD. The participants chose different approaches, according to the type and severity of the symptoms, to cope with them and to avoid the risk of recurrence. Among these behaviours, all participants rested or reduced activities rst:
If I perceive worsening of breathlessness, I rest. A lot of things need to be done, but I wait because of breathlessness.

work, [I was] almost out of breath. I used A + B [nebulized ipratropium and terbutaline sulphate].

Five participants tried diaphragmatic breathing or pursed-lip breathing when they had shortness of breath. They also used effective coughing to clear the sputum in their respiratory tract:
Take a deep breath like this. The respiratory therapist taught me: in 1, 2 and out 1, 2, 3, 4. Thats it. Inhale 2 seconds and exhale for 4 seconds. Take it easy.

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JAN: ORIGINAL RESEARCH I use this method [hufng] to clear my sputum. When I apply the method, the sputum in my lungs will move and be expelled after ve or six times.

Self-management behaviours exercise once in the morning and once in the evening. Rainy days keep me in the house, but I still exercise. Sometimes I shake my legs, not because I am sick. I do it on purpose.

When they experienced symptom exacerbation, participants used approaches based on their past disease-management experience. If the methods did not work, they would change their approach or ask a family member to take them to the doctor. One participant (with COPD of moderate severity), who lived next door to his son, stated:
I drink some warm water and walk a while at my house when I feel uncomfortable. If the situation gets worse, I call my son to give me a massage. If it doesnt help, I go to the ER.

Environmental control
Participants kept themselves in stable condition using household appliances and clothing:
I will wear enough clothes. When I am not sleeping during the daytime, I use an air lter and turn on the heater at night. I turn the heater to a higher temperature on colder days. It is easy for me, at my age, to catch cold if I get up at night to urinate and do not put on enough clothes.

Another, an 80-year-old widower, whose condition was severe, lived with his sons family. He stated:
Sometimes, I suffer from shortness of breath and I cant move, but am conscious. My son moves me to my bed and covers me with a blanket to keep me warm. He uses a hot towel to massage my chest, hands, and feet, with red-ower oilSometimes, if I have a bout at six in the morning, I wake them up. I use a bell to wake them.

Most participants were 65 years and older and their families arranged the furniture to provide easy access and to prevent them from falling and experiencing dyspnoea:
I have a table in my room, about one to two metres away from my bed. Thats my area.

According to a family member of one participant whose condition was severe:

The important thing was to prevent him from falling and to keep his moving route simple and clear.

Activity and exercise implementation

To keep their condition stable and to avoid dyspnoea, patients must assess their physical condition and, based on their prior experience, choose appropriate behaviours for their daily activities and exercise. Some of the participants who had accepted rehabilitation instructions exercised according to their doctors prescription:
The pulmonary therapist told me to exercise, so now I get up at 4 in the morning to exercise. Now, when I am told to exercise, I listen. They are doctors and nurses who have experience. We know nothing. You should just follow the orders.

Some participants would evaluate the air quality outdoors and in public places and avoided going to places with terrible air quality:
The stagnant air keeps me from going out, even though Id rather go to the park for exercise at four in the morning. I seldom go to the parties or gatherings. I dont like to dine out in restaurants that are lled with second-hand smoke. Id rather not go if I dont have to.

All participants lowered the speed and shortened the distance of their walking, based on their condition:
I am breathless if I walk fast, but I am ne walking at a normal speed. So I walk steadily. No, I dare not to walk too far. I walk around the alleys close to my house for a few minutes to half an hour.

Emotional adaptation
Chronic obstructive pulmonary disease has a psychosocial impact. Participants made an effort to change negative thoughts into positive ones and to control emotional disturbances, which decreased the potential negative inuences on their disease:
You need to stand up bravely even if you are uncomfortable. Ageing is a period of lifetime; it is just like a machine that will be out of order some day. For now, I just keep this way. Exercising and rehabilitation are for extending my life. The road, dying, is a way that every one will take, even the presidentThere is no way to change

Choosing sedentary activity and alternative methods is one type of self-management behaviour:
It rains, so I stay home and walk around my house 40 or 50 circles, about 70 steps for a circle. I wont have shortness of breath nowI

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K.-H. Chen et al. that. To live one more day, exercising is good for your health. If you dont do it, you die soon. I cant quit. I have been smoking for 60 years. It is not possibleMy colleagues quit smoking and came up with many [physical] problems. So I just smoke less.

Some thought they should accept that the disease was due to fate:
We have treatment, but the disease was not cured, so I have to face my fate. Why are all the others healthy and I got the diseases? Sometimes I do feel pessimistic. The only thing I can do is to continue the treatment and take care of myself until I cant live anymore.

Discussion
Study limitations
The sample size was relatively small but, because this was a qualitative study, it provided rich data and a culturally sensitive perspective on COPD embedded in Chinese culture. However, theme saturation was achieved and the usefulness of the data is a more important concern than the generalizability of the ndings. Data were collected in a medical centre in Northern Taiwan. Because the hospital had a pulmonary recovery room and a respiratory therapy room, it provided better care for patients, as compared to other regional hospitals and clinics. Thus, most of the participants had received better health education than patients in other hospitals. Therefore, they may have been more willing to follow the instructions of healthcare professionals and more creative in their selfmanagement behaviours. The nal limitation is that all participants were male and most were in late adulthood. Family is the most important thing to them and their health is secondary in terms of personal investment (Santrock 2004). Although the study was limited to men, no gender differences have been found in other research into self-management and self-care with COPD and other chronic diseases (Xiaolian et al. 2002, Cicutto et al. 2004, Monninkhof et al. 2004, Cicutto & Brooks 2006, Fraser et al. 2006, Fu et al. 2006). Only one researcher found gender differences in behaviour to control breathing (Nield 2000).

Getting used to the symptoms is one of the behaviours involved in emotional adaptation:
Theres nothing. I am always like this. I am not comfortable sometimes and later I am okay as long as I am not having shortness of breath. I used to be depressed and uncomfortable, but now I am used to it.

Maintaining a healthy lifestyle

Exercising and taking medication on a regular basis helped prevent the occurrence of symptoms:
A healthy lifestyle means getting up early and going to sleep early. However, for my kind of disease, I could not get up too early because it is cold. I never get up early in the winter, but I do in the summer. I always follow the doctors orders in taking my medicine. You must take medication until the doctor tells you not to or to lower the dosage.

Some interviewees controlled their diet. They avoided eating cold food or having cold drinks:
Do not eat cold food. Heat it when you want to eat it. Cold food triggers coughs. It is better to eat warm food.

Some participants learned Chinese Kung Fu and alternative methods to improve their condition:
I do Chi Kung; its very helpful. I do it every dayit worksit is great for the lungs. I drink a cup of ginseng wine everyday. I used to have high blood pressure and high cholesterol. Now these problems wont bother me.

Discussion of ndings
Self-management behaviour Self-management is aimed at maintaining or improving health and preventing disease. Although self-management behaviours should integrate different types of information, skills, attitudes, values and environmental reinforcement so as to maintain wellness, they do not involve merely following instructions (Bartholomew et al. 1991, Deaton 2000). Although following instructions is necessary, participants viewed healthcare professionals as teachers and monitored themselves for disease symptoms and developed their own solutions to their illness. Our ndings can broaden healthcare professionals knowledge of disease self-management

Some participants quit smoking or decreased tobacco inhaling:

Now Ive quit smokingBefore, I wanted to quit, but did not think my sickness was seriousor relevant. People are like that. They will never quit unless struggling until the last minute, right? 600

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behaviours of patients with COPD and can contribute to optimizing self-management practices that promote patients quality of life. Symptom management Chronic obstructive pulmonary disease has an impact on patients physiological and psychosocial health (ONeill 2002, Cicutto et al. 2004, Cicutto & Brooks 2006, Fraser et al. 2006). Often, in COPD of different levels of severity, the impact of dyspnoea can be overwhelming, as has been shown in a number of studies (Nield 2000, ONeill 2002, Fraser et al. 2006). Dyspnoea affects both physical endurance and functional ability. Moreover, emotional uctuations are frequently associated with the physical impact of the disease (Fraser et al. 2006). Therefore, dyspnoea management and prevention are the rst priority of self-management behaviours. To prevent dyspnoea, patients must learn activity modication, positioning and movement techniques, avoiding potential dyspnoea stimuli (e.g. wind, heat, stagnant air and crowds), new eating habits, relaxation techniques and acceptance of the illness and its limitations (Nield 2000, Seamark et al. 2004, Christenbery 2005, Froggatt & Walford 2005, Maher & Hemming 2005, Prigmore 2005). Such behaviours correspond to the sub-themes found in this study. Research has shown that the most effective strategies for managing dyspnoea are calling the physician, doing breathing exercises, using medication and reducing activity (Nield 2000, ONeill 2002, Cicutto et al. 2004, Cicutto & Brooks 2006). Our ndings were consistent with such research. When dyspnoea occurs, patients with COPD rst will choose rest and reduction of activity. However, as the disease progresses, the patient will experience dyspnoea at rest. This will cause the patient to become increasingly immobile, resulting in decreased ability to exercise, social isolation and lowered mood states (GOLD 2006). To reduce the frequency and severity of breathlessness, healthcare professionals should teach patients, as soon as possible, about controlled breathing, self-medication adjustment and interacting appropriately with healthcare providers (Gosselink 2003, Maher & Hemming 2005). Oxygen therapy is used to treat hypoxia and palliate dyspnoea (Christenbery 2005, Prigmore 2005). Although many patients claim that it is of psychological benet, there are few randomized control trials on the effectiveness of oxygen therapy for the palliative relief of breathlessness in COPD (Booth et al. 2004, Prigmore 2005). In our study, the most of participants had not used oxygen, fearing that it could be addictive. In our study, 15 participants had received instructions about inhalants, respiratory control, airway clearance, and

exercises, and these enabled them to self-manage their disease. The remaining three participants had only received instructions on the inhalant, one of whom complained that the doctors did not give him enough guidance during outpatient services and another who said that many doctors did not demonstrate caring behaviours. These ndings suggest that doctors play a key role in motivating patients to attend pulmonary rehabilitation programmes and that health education and healthcare professionals communication skills are essential for the self-management of chronic disease (Lorig et al. 2000, Bourbeau et al. 2003, Arnold et al. 2006, Wilde & Garvin 2007). Most of our participants lived with or near their families. Even if they did not live in the same house, they lived next door or upstairs. The family kinship system in Taiwan is different from that of Western families. The Chinese family is a father son dominated kinship system, which has special features of continuity and inclusiveness (Hsu 1973). Xiaolian et al. (2002) conducted research into patients family support with COPD in the Peoples Republic of China and found that the family rst ideology encouraged family members to promote their family members health. Thus, our participants with moderate and severe COPD tended to ask family members to send them to the hospital when their self-management failed. When patients experienced symptom exacerbation, they would try a number of approaches before asking others to take them to the ER. Managing acute episodes and emergencies is an important self-management activity that involves more than the use of medication (Clark et al. 1991). Professionals should work with people who have COPD to determine what they are able to do to control their symptoms (Lorig et al. 2000, Jerant et al. 2005). Activity and exercise implementation Taiwan is situated in a sub-tropical zone and thus there is a great deal of rainfall and the average temperature is high. Because the heat can easily cause dyspnoea and wet roads can lead to slipping, participants needed to choose sedentary activities and alternative methods of exercise, for example walking around inside the house or shaking their limbs. In our study, 15 participants participated in a few weeks or months of pulmonary rehabilitation, but only three continued to exercise on a regular basis. Cicutto et al. (2004) studied self-care experiences through seven focus groups and found that, although participants believed that exercising helped to maintain functioning, they stated that it was difcult to exercise. It was the last thing they wanted to do. However, because survival relied on adjusting to the physical limitations inicted by the disease, they attempted to maintain a balance between disease management and their desired
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What is already known about this topic

Many patients with chronic obstructive pulmonary disease do not show severe airow limitation and have not been diagnosed and therefore the prevalence statistics are an underestimate. Chronic obstructive pulmonary disease has an impact on physiological and psychosocial health. Previous studies have focused on specic issues associated with chronic obstructive pulmonary disease, such as self-care activities, living experiences, dyspnoea management and emotional problems.

cold or air pollution, could result in an unstable condition. Participants realized this and used appliances or clothes (e.g. jackets, masks) to stay warm and dry. When going out, they avoided stimuli such as wind, weather extremes, crowds during the inuenza season and stagnant air. Such behaviours were also noted in previous reports (Nield 2000, ONeill 2002). One environmental control behaviour not reported in the previous studies was arranging furniture to increase convenience and prevent falling. These behaviours conserved energy, prevented dyspnoea and avoided complications produced by falling and showed that self-care wisdom and family support were important in self-management. Emotional adaptation Living with COPD may be synonymous with living with dyspnoea (Fraser et al. 2006). Dyspnoea not only affected participants physiological condition, but also had an impact on their psychological health. They used self-talk, relaxation and positive attitude to reduce psychological distress and promote emotional health, and these ndings are similar to those of other researchers (Nield 2000, ONeill 2002, Cicutto et al. 2004). The mean time as diagnosis in the current study was 891 years. During that time, some participants had become used to the negative effects of the disease. In addition, because of the inuence of Daoism, the Taiwanese accept their fate and get used to the symptoms as a means to take care of themselves. Most participants understood that COPD was not curable. They tried to get used to their physical condition and followed the guidance of healthcare professionals. Maintaining a healthy lifestyle Some behaviours concerned with maintaining a healthy lifestyle, such as engaging in Chi Kung, drinking ginseng, and not eating tangerines or cold food, were based on traditional Chinese medicine and are generally not seen in Western countries. In emergency situations, participants also used complementary therapy, such as a massage with red-ower oil. This demonstrates that cultural factors inuence COPD selfmanagement behaviours. When the Chronic Disease SelfManagement Programme was implemented in Shanghai in the Peoples Republic of China, patients noted the absence of physical activities and relaxation exercises with which they were familiar and comfortable. Thus, Fu et al. (2006) suggested that such exercises be added to the Chinese programme. Taiwanese ethnicity includes Aborigines, Mainlanders, Fukiens and Hakkas and each group has its own customs and habits, while Western countries have more cultural diversity than Taiwan (Anderson et al. 2007).

What this paper adds

Patients with chronic obstructive pulmonary disease chose suitable disease self-management behaviours, based on experience, wisdom and professional guidance. Cultural factors inuence patients self-management behaviours. Patients integrate environmental control behaviours into their lives, and these should be taken into account in self-management programmes.

lifestyle (ONeill 2002, Cicutto et al. 2004). Thus, they shifted from an active to a sedentary lifestyle and chose alternative methods of activity. Because the mean age of participants was 7406 years, many needed relatives to accompany them to attend the rehabilitation programme at the hospital. However, most not only lacked motivation, but also were not willing to inuence the familys work schedule. In addition, they found pulmonary rehabilitation too time consuming. After 2000, however, home and clinic programmes replaced rehabilitation in hospitals (Monninkhof et al. 2003, Gallefoss 2004, Murphy et al. 2005), indicating that disease self-management has become recognized as an effective approach. Therefore, healthcare professionals should not only focus on patients health problems, but also on their motivation for selfmanagement. It is also important for professionals to educate and discuss with family members the benets of selfmanagement, as the family is a necessary support system for self-care (Nield 2000). Such knowledge not only enables family members to help chronically ill patients, but also to help themselves (Fu et al. 2006). Environmental control Environmental control is an important issue in the lives of patients with COPD. Any environmental risk factor, such as
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Therefore, healthcare teams should be multicultural, and include personnel who can understand these different cultures. Smoking cessation is one management component for COPD and the most cost-effective way to reduce exposure to COPD risk factors (GOLD 2006). In this study, many participants had tried to quit smoking but, because they lacked knowledge of smoking cessation resources, they did not seek professional counselling. Healthcare providers are key to the delivery of smoking cessation messages and interventions (GOLD 2006) and should encourage all patients with COPD who smoke to quit.

intellectual content. KHC and HYC performed the data collection. KHC and LCW performed the data analysis. KHC and MLC were responsible for the drafting of the manuscript. MLC obtained funding. HYC provided administrative, technical or material support.

References
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Conclusion
Patients with COPD use a variety of behaviours to manage their disease and to prevent and alleviate symptoms, as well as to maintain quality of life. No matter what the level of severity, the 18 participants tended to adopt all ve themes of self-management behaviour, some of which were inuenced by Chinese traditional medicine. Rearrangement of furniture, however, has not been reported in previous studies. Dyspnoea is the most common and terrifying symptom experienced by patients with COPD (GOLD 2006). As such, it needs holistic nursing assessment and management. Nurses should adopt an active role in supporting and helping patients to adapt to physiological and psychosocial changes by maximizing selfmanagement behaviours. It should be noted that widespread global migration is occurring and that healthcare delivery systems in Western nations are undergoing restructuring (Anderson et al. 2007). Our ndings suggest that healthcare professionals and researchers must be more sensitive to cultural diversity and that healthcare teams should have culturally diverse members so that, when designing self-management programmes, cultural factors and environmental control behaviour are taken into consideration.

Acknowledgements
We would like to thank all the patients who participated in this study, and Chun-Hua Wang, Director of Airway Disease Division, for his assistance with the study. The study was supported by a research grant from Chang Gung Memorial Hospital to Dr Mei-Lin Chen (grant number: CMRPD 150241).

Author contributions
KHC, MLC and SL were responsible for the study conception and design, made critical revisions to the paper for important

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