Health-related quality of life and associated factors among patients with chronic obstructive pulmonary disease in Addis Ababa, Ethiopia: a multicentre cross-sectional study

Abstract

Objective

This study aimed to assess health-related quality of life (HRQoL) and identify associated factors among patients with chronic obstructive pulmonary disease (COPD) attending selected hospitals in Addis Ababa, Ethiopia.

Design and setting

A hospital-based multicentre cross-sectional study was conducted among 205 patients with COPD attending the chest clinics of selected hospitals in Addis Ababa, Ethiopia, from June 2023 to December 2023.

Participants

A total of 205 patients with COPD who had follow-up at outpatient departments of the chest clinic of the selected hospitals were included in the study.

Main outcome measures

The main outcome of this study was HRQoL, which was assessed using the validated COPD Assessment Test-Amharic version (CAT-Am). Data analysis was performed using Stata version.17, and multivariable linear regression was employed to examine the relationship between HRQoL and independent variables. Variables with p-values <0.05 at a 95% CI were considered statistically significant.

Results

The mean score of the overall CAT-Am was 20.24±8.13. Older age (β=0.11, 95% CI: 0.04 to 0.17), poor social support (β=2.49, 95% CI: 0.74 to 4.24), biomass fuel exposure (β=4.57, 95% CI:3.17 to 5.97), Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages 2, 3 and 4 (β=2.12, 95% CI: 0.23 to 4.01; β=3.38, 95% CI: 1.11 to 5.66; β=5.20, 95% CI: 2.37 to 8.05, respectively), presence of comorbidity (β=4.03, 95% CI: 2.48 to 5.59), increased number of hospitalisations in the past year (β=2.78, 95% CI: 1.68 to 3.88), increased number of prescribed medications (β=0.40, 95% CI: 0.10 to 0.70), low medication adherence (β=2.79, 95% CI: 1.13 to 4.46), and moderate medication adherence (β=3.38, 95% CI: 1.65 to 5.11) were negatively associated with HRQoL.

Conclusion and recommendations

In this study, patients with COPD had poor HRQoL, which indicates that patients need multidisciplinary interventions. Older age, poor social support, an increased number of prescribed medications, an increased number of hospitalisations in the past year, biomass fuel exposure, low and moderate medication adherence, GOLD severity stages 2, 3 and 4, and the presence of comorbidities require close follow-up to improve HRQoL. Further research should evaluate targeted strategies to address these determinants.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This is a multicentre study, including both private and public hospitals, which improves generalisability.

• The study used a validated tool to measure health-related quality of life

• Despite these advantages, the use of self-reported questionnaires may introduce recall bias.

• Due to the cross-sectional design, it is difficult to establish a causal relationship.

• The results may not be applicable to all patients with chronic obstructive pulmonary disease in the community due to the hospital-based setting.

Introduction

Chronic obstructive pulmonary disease (COPD) is a heterogeneous lung disease characterised by persistent respiratory symptoms and airflow limitation that is not fully reversible.^{1 2} It is a major cause of morbidity and mortality worldwide; COPD affects millions of people and significantly contributes to the burden of non-communicable diseases, especially in low-income and middle-income countries.³ The prevalence of COPD is high in East Africa, estimated at 13.3%,⁴ with Ethiopia reporting an even higher prevalence of 17.8%.⁵ COPD has significantly impaired health-related quality of life (HRQoL); in addition, physical manifestations, frequent exacerbations, persistent symptoms, comorbidities and treatment-related challenges contribute to physical limitations, social restriction and psychological distress, collectively leading to a decline in patients’ well-being.^{6 7}

HRQoL is a multidimensional construct that encompasses psychological, social and physical health domains to determine how overall well-being influences quality of life (QoL).^{8 9} Evidence consistently demonstrated that individuals with COPD reported lower HRQoL compared with the general population.^{10 11} In recognition of this impact, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline identifies improving HRQoL as a key therapeutic goal in the management of COPD.¹² Furthermore, previous studies emphasised the need to monitor HRQoL to better understand the disease’s burden and evaluate treatment outcomes.13,15 However, developing effective interventions to improve QoL in patients with COPD requires a thorough understanding of the factors associated with poor HRQoL. Previous studies have identified several potential predictors, including smoking status, comorbidities and frequent exacerbation,16,18 as well as disease severity and duration of illness.^{19 20} In addition, advanced age has been associated with reduced HRQoL in patients with COPD across multiple studies.^{21 22} Other predictors include medication adherence,^{23 24} hospitalisation history²⁵ and modified Medical Research Council (mMRC) dyspnoea score.²⁶ Understanding these factors is crucial for stratifying patients and tailoring interventions to address their specific needs. Despite the growing burden of COPD, there remains a paucity of studies assessing HRQoL among patients with COPD in Ethiopia. Therefore, comprehensively assessing the impact of COPD on patients’ daily lives is essential for effective disease management and for enhancing their overall HRQoL. Accordingly, this study aimed to assess HRQoL and identify factors associated with poor HRQoL among patients with COPD.

Materials and methods

Study setting, period and design

A cross-sectional study was conducted at Tikur Anbessa Specialized Hospital (TASH), St. Paul’s Hospital Millennium Medical College (SPHMMC) and Lancet General Hospital (LGH) from June 2023 to December 2023 in Addis Ababa, Ethiopia; TASH and SPHMMC are the largest referral and tertiary hospitals in Ethiopia. These hospitals provide a wide range of specialised clinical services. LGH is a private hospital and a prominent referral centre with multidisciplinary care, including respiratory disease.

Population, inclusion and exclusion criteria

The source population comprised all adult patients aged 18 years and older with a physician diagnosis of COPD who received regular follow-ups at the outpatient chest clinics across three hospitals (two tertiary and one private) in Addis Ababa, Ethiopia.

The study population included all adult patients aged ≥18 years with COPD who had regular follow-ups at the outpatient departments of the chest clinics of TASH, SPHMMC and LGH during the study period. Patients were included with a clinical diagnosis of COPD confirmed with spirometry, were clinically stable (no acute exacerbation) within the preceding 6 months and had at least two previous visits and current pharmacologic treatment for COPD. Patients who had undergone lung surgery; had uncontrolled lung cancer, tuberculosis, pulmonary hypertension or cognitive impairment; or who refused to participate were excluded from the study because these conditions independently affect HRQoL.

Sample size determination

The minimum sample size was calculated using the single population proportion formula.

$$n=\frac{Z^2\raisebox{1ex}{$\alpha $}\!\left/ \!\raisebox{-1ex}{$2$}\right.\mathrm{*}P(1-p)}{W^2}$$

Assuming a 95% confidence level (Z=1.96), a margin of error (W=0.05) and a proportion of 50% (P=0.5), since there are no prior studies in the setting. The initial sample size was calculated as n=1.962*0.5 (1–0.5)/0.05², n=384. Since the number of populations was less than 10 000, the finite population correction formula was applied, yeilding an adjusted sample size of 194: after adding a 5% non-response rate, the final calculated sample size was (194+10) ≈ 205.

Sampling technique and procedure

Three hospitals in Addis Ababa, Ethiopia—TASH, SPHMMC and LGH—were selected using the lottery method. The total number of patients with COPD on follow-up within the past 6 months was obtained from patients’ registration cards to allocate samples proportionally across the study sites. After proportional allocation, a simple random sampling technique was employed to select the study participants. In total, 205 participants were recruited and distributed according to each hospital’s patient population size: LGH (22 participants from 42 patients), SPHMMC (88 participants from 167 patients) and TASH (95 participants from 181 patients).

Study variables

HRQoL was the main outcome variable. The independent variables were sociodemographic characteristics of the participants such as age, social status and health insurance, as well as clinical characteristics including initial symptoms, presence of comorbidities, duration of illness, current medication, number of prescribed medications, number of exacerbations in the past year, number of hospitalisations in the past year, body mass index (BMI), forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), FEV1/FVC, the GOLD severity stage, the GOLD ABE assessment tool (groups A, B and E), medication adherence and the mMRC dyspnoea scale.

Data collection instrument, procedures and quality control

All patients attending the chest clinics for follow-up were assessed for eligibility. Patients who met the eligibility criteria were recruited by the investigator, informed about the objectives of the study and obtained an informed consent. A standardised questionnaire and patient medical document abstraction were used to collect data. A four-section data-collecting tool was created after a review of relevant literature to capture participants’ demographic and clinical characteristics to investigate HRQoL. It was translated into the local Amharic language and then back-translated to the English version to ensure consistency and accuracy.

The first section contained questions designed to collect participants’ sociodemographic information, including sex, age, marital status, place of residence, religion, educational status, occupation, social support, health insurance status and income level. The second section comprised clinical characteristics, such as the GOLD classification and mMRC dyspnoea scale.

The third section included the HRQoL measurement tool, the COPD Assessment Test-Amharic version (CAT-Am), and the fourth questionnaire, the Adherence in Chronic Disease Scale (ACDS).

HRQoL was assessed using CAT-Am and categorised into four levels based on the CAT score: low (1–10), medium (11–20), high (21–30) and very high (31–40).²⁷

Medication adherence was assessed using the ACDS, which consists of seven items. Questions 1–5 assess patients’ medication-related behaviours, and questions 6 and 7 concern the physician–patient relationship. Each item on the scale is assigned 0–4 points based on the response. The total medication adherence score ranged from 0 to 28. A patient with a total score greater than 26 was classified as having high adherence to treatment, while scores of 21–26 and <21 score indicate medium and low adherence, respectively.²⁸

The data were collected by three experienced BSc nurses. The data collectors interviewed participants to obtain the required information, and the principal investigator closely supervised and followed up to ensure the completeness, accuracy and consistency of the data throughout the process. Additionally, essential feedback was given to the data collectors at the end of each collection session.

A pretest of the questionnaire was conducted on 5% of the study population, involved 11 patients with COPD at TASH and these data were not included in the final analysis. The pretest results were used to refine ideas and statements in the questionnaire. Based on their feedback, unclear items were removed, culturally inappropriate words were corrected and some formatting was improved.

Operational definitions

COPD exacerbation

An acute and clinically significant change in the patient’s daily symptoms that results in a change in therapy.²⁹

Medication adherence levels

Medication adherence is defined as the extent to which patients take their medications as prescribed by their healthcare providers.³⁰ The ACDS total score indicates the adherence level; a score of less than 21 signifies low adherence, a score between 21 and 26 indicates medium adherence, and a score greater than 26 reflects high adherence.³¹

Current smoker

Current smoker refers toa person who has smoked more than 100 cigarettes throughout their lifetime and has smoked within the past 28 days.³²

Ex-smoker

An ex-smoker is defined as a person who has smoked more than 100 cigarettes throughout their lifetime but has not smoked in the past 28 days.³²

Non-smoker

A non-smoker is defined as a person who has smoked fewer than 100 cigarettes throughout their life time and does not smoke now.³²

Health-related quality of life

Based on the score of CAT-Am eight items, with a total a score ranging from 0 to 40, with scores approaching 40 indicates poorer HRQoL, while scores approaching zero indicate better HRQoL.

Data analysis and interpretation

All the questionnaires were manually reviewed to ensure the completeness and consistency of the responses. The data were cleaned, and there were no missing values for variables included in the final analysis. Data were entered into Excel and analysed using Stata version.17. Categorical variables were summarised using frequencies and percentages. The normality of continuous variables was verified via the Shapiro-Wilk test. For normally distributed data, the results are displayed as the mean and SD, and for non-normally distributed data, the results are shown as the median and IQRs. Variables with a p value <0.2 from the bivariate test were selected as candidate variables for the multivariable linear regression analysis. This analysis aimed to identify possible predictors of HRQoL. A p value of <0.05 was considered statistically significant. The study was reported in compliance with the STROBE guidelines.

Patient and public involvement

None.

Results

Sociodemographic characteristics of the study participants

A total of 205 patients participated in the study. The mean age was 63.08 years (SD=11.04). More than half of the participants were male (60.49%), married (53.17%), people who did not smoke (60%), exposed to biomass fuel (57.07%) and lived in an urban area (82.44%). More details about the sociodemographic characteristics of the study sample are presented in table 1.

Table 1. Sociodemographic characteristics of the study participants (n=205).

Variables	Categories	Frequency (%)
Age (years)	Mean±SD	63.08±11.04
Sex	Male	124 (60.49)
	Female	81 (39.51)
Average monthly income (Ethiopian birr)	Mean±SD	7300.22±5322.54
Educational status	Illiterate	51 (24.88)
	Primary school	71 (34.63)
	Secondary school	42 (20.49)
	Higher education	41 (20.00)
Marital status	Married	109 (53.17)
	Single	20 (9.76)
	Widowed	66 (32.20)
	Divorced	10 (4.88)
Residence	Rural	36 (17.56)
	Urban	169 (82.44)
Biomass fuel exposure	No	88 (42.93)
	Yes	117 (57.07)
Smoking status	Current smoker	11 (5.37)
	Ex-smoker	71 (34.63)
	Non-smoker	123 (60.00)
Amount of smoking (pack-years)	Median (IQR)	22 (16–30)
Duration of smoking (years)	Median (IQR)	25 (20–30)
Occupational status	Farmer	16 (7.80)
	Housewife	24 (11.71)
	Merchant	28 (13.66)
	Unemployed	32 (15.61)
	Employee	59 (28.78)
	Retired	46 (22.44)
Social support	No	33 (16.10)
	Yes	172 (83.90)
Health insurance	No	55 (26.83)
	Yes	150 (73.17)

Clinical characteristics of the study participants

The most common initial symptom was dyspnoea (38.05%); the mean duration of illness was 2.51 (SD=2.29) years; grade 1 and grade 4 were the most common mMRC dyspnoea score, each reported by patients (26.83%), and inhaled corticosteroid (ICS) combined with long-acting beta-2 agonist (LABA) was the most commonly used regimen (45.85%). According to GOLD, 27.32% were GOLD stage 1 (mild), and 15.12% were GOLD stage 4 (very severe). More detailed clinical characteristics of the study sample are presented in table 2.

Table 2. Clinical characteristics of the study participants (n=205).

Variables	Categories	Frequency (%)
Initial symptoms	Fatigue	26 (12.68)
	Dyspnoea	78 (38.05)
	Cough	73 (35.61)
	Wheezing	28 (13.66)
Duration of illness (years)	Mean±SD	2.51±2.29
Presence of comorbidities	No	65 (31.71)
	Yes	140 (68.29)
Current COPD treatment	ICS+LABA	94 (45.85)
	ICS+LABA/SABA	64 (31.22)
	SABA	29 (14.15)
	ICS+SABA	10 (4.88)
	Oxygen	8 (3.90)
Number of prescribed medications	Mean±SD	4.90±2.28
GOLD ABE assessment tool	Group A	56 (27.32)
	Group B	59 (28.78)
	Group E	90 (43.90)
Body mass index (kg/m2)	<18.5	95 (46.34)
	18.5–24.9	81 (39.51)
	≥25	29 (14.15)
mMRC dyspnoea scale	Grade 0	25 (12.20)
	Grade 1	55 (26.83)
	Grade 2	32 (15.61)
	Grade 3	38 (18.54)
	Grade 4	55 (26.83)
FEV1	Mean±SD	59.43±23.70
FVC	Mean±SD	90.2±31.38
FEV1/FVC	Mean±SD	62.76±8.56
Number of hospitalisations in past year	Mean±SD	1.00±0.74
Number of exacerbations in the past year	Mean±SD	2.17±0.83
Low adherence	Mean±SD	82±40.00
Moderate adherence	Mean±SD	50±24.37
High adherence	Mean±SD	73±35.61
GOLD severity	Mild	56 (27.32)
	Moderate	59 (28.78)
	Severe	59 (28.78)
	Very severe	31 (15.12)

ABE, assessment tool (groups A, B and E); COPD, chronic obstructive pulmonary disease; FEV1, forced expiratory volume in 1 s; FVC, forced vital capacity; GOLD, Global Initiative for Chronic Obstructive Lung Disease; ICS, inhaled corticosteroid; LABA, long-acting beta-2 agonist; mRC, modified Medical Research Council dyspnoea scale; SABA, short-acting beta-2 agonist.

Most common types of comorbidities

The majority (68.29%) had comorbid conditions. Hypertension was the most frequently reported comorbidity (22.35%), followed by diabetes mellitus (14.12%) and major depressive disorder (12.35%).

HRQoL of participants

According to CAT-Am scores, most participants (46.34%) were classified as severe, followed by moderate (24.88%)and a small proportion (8.78%) were in the very severe category. The overall mean score of HRQoL among participants with COPD was 20.24, with an SD of 8.13. (table 3).

Table 3. Distribution of COPD severity based on COPD Assessment Test-Amharic version scores.

Categories	Frequency (n=205)	%
Mild	41	20.00
Moderate	51	24.88
Severe	95	46.34
Very severe	18	8.78

COPD, chronic obstructive pulmonary disease.

Factors associated with overall HRQoL

Multivariable linear regressionanalysis

The regression model produced a significant F-statistic of 27.78 (df=18, 186; p<0.001). The model accounted for 72.89% of the variation in the CAT-Am scores (R² =0.7289) and had an adjusted R² of 0.7026, indicating a good model fit. The root mean square error was estimated at 4.43, indicating the average deviation of the predicted values from the observed values. Twelve variables were used for multivariable linear regression analysis; among those, eight variables were identified as associated with HRQoL by stepwise and forward multivariable linear regression methods.

The multivariable linear regression results showed that older age (β=0.11, 95% CI: 0.04 to 0.17, p=0.001), poor social support (β=2.49, 95% CI: 0.74 to 4.24, p=0.005), exposure to biomass fuel (β=4.57, 95% CI: 3.17 to 5.97, p<0.001), an increased number of prescribed medications (β=0.40, 95% CI: 0.10 to 0.70, p=0.010), an increased number of hospitalisations in the past year (β=2.78, 95% CI: 1.68 to 3.88, p<0.001), low medication adherence (β=2.79, 95% CI: 1.13 to 4.46, p=0.001), moderate medication adherence (β=3.38, 95% CI: 1.65 to 5.11, p<0.001), GOLD stage 2 (β=2.12, 95% CI: 0.23 to 4.01, p=0.028), GOLD stage 3 (β=3.38, 95% CI: 1.11 to 5.66, p=0.004), GOLD stage 4 (β=5.20, 95% CI: 2.37 to 8.05, p<0.001) and the presence of comorbidities (β=4.03, 95% CI: 2.48 to 5.59, p<0.001) were associated with poorer HRQoL (table 4).

Table 4. Factors associated with health-related quality of life of patients with COPD (n=205).

Variable	Categories	ß	95% CI	Pvalue
Age (years)	–	0.105	0.044 to 0.167	0.001
FEV1	–	0.015	−0.022 to 0.052	0.433
Number of hospitalisations in the past year	–	2.781	1.679 to 3.883	<0.001
Number of exacerbations in the past year	–	0.147	−0.776to 1.071	0.753
Biomass fuel exposure (no)	No	Ref
	Yes	4.572	3.173 to 5.971	<0.001
Social support (yes)	Yes	Ref
	No	2.492	0.743 to 4.242	0.005
Duration of COPD illness		0.132	−0.149 to 0.412	0.355
Number of medications		0.400	0.098 to 0.703	0.010
GOLD severity	1	Ref
	2	2.115	0.225 to 4.005	0.028
	3	3.383	1.105 to 5.661	0.004
	4	5.208	2.369 to 8.047	<0.001
mMRC dyspnoea scale	Grade 0	Ref
	Grade 1	0.560	−1.629 to 2.748	0.614
	Grade 2	1.324	−1.194 to 3.842	0.301
	Grade 3	0.023	−2.485 to 2.533	0.985
	Grade 4	0.197	−2.230 to 2.623	0.873
Medication adherence	low adherence	2.793	1.131 to 4.455	0.001
	Moderate adherence	3.379	1.646 to 5.112	<0.001
	High adherence	Ref
Presence of comorbidity	No	Ref
	Yes	4.033	2.475 to 5.590	<0.001

COPD, chronic obstructive pulmonary disease; FEV1, forced expiratory volume in 1 s; GOLD, Global Initiative in Chronic Obstructive Lung Disease; mMRC, modified Medical Research Council dyspnoea scale; Ref, reference.

Discussion

Patients with COPD have significantly impaired HRQoL at all levels of severity of the disease, including those with mild COPD.33,35 The findings of this study provide a foundation for the development of future pharmaceutical care interventions aimed at improving medication adherence and symptom control through pharmacological as well as non-pharmacological interventions, including patient education about medication adherence, promotion of physical activities and decreasing exposure to biomass exposures aimed at improving the HRQoL and optimising health outcomes for patients with COPD. Although COPD is a leading cause of morbidity and mortality worldwide, its impact on HRQoL in Ethiopian patients has not been adequately studied. Aiming to assess HRQoL and its associated factors, this study revealed that patients with COPD had poor HRQoL. In addition, older age, poor social support, biomass fuel exposure, low and moderate medication adherence, increased number of hospitalisations, presence of comorbidities, increased number of prescribed medications and advanced GOLD stage were significantly associated with HRQoL.

The current study findings indicated that patients with COPD in Ethiopia experience poor HRQoL, which is consistent with studies conducted in Nigeria³⁶ and China³⁷; it is also supported by earlier studies assessing HRQoL among patients with COPD.1020 38,40 The current study revealed that older individuals with COPD had poorer HRQoL compared with younger participants. Previous studies report similar findings.^{10 41 42} The reduced HRQoL observed among elderly individuals may be related to the increasing deterioration in lung function, social isolation and the presence of various comorbidities that cumulatively impair HRQoL. These findings underscore the need of administering tailored therapies to enhance the HRQoL of elderly individuals.

The study demonstrated that patients with poor social support reported poorer HRQoL than those who have social support. This finding is consistent with evidence from the Netherlands,⁴³ the USA⁴⁴ and Taiwan,⁴⁵ as well as a recent systematic review that revealed the negative impact of poor social support on the HRQoL of patients with COPD.⁴⁶ Patients with COPD who have poor social support frequently struggle with medication adherence and disease management, which worsens symptoms, causes frequent exacerbations and contributes to poor HRQoL. This finding revealed the need to strengthen social support through family involvement, encouraging community participation and offering structured counselling, which should be considered a vital component of comprehensive COPD management.

The present study demonstrated that patients with COPD exposed to biomass fuel reported poorer HRQoL than those not exposed to biomass fuel. This finding is consistent with previous studies from China,⁴⁷ India^{48 49} and a systematic review and meta-analysis by Po et al.⁵⁰,⁵⁰ These results underscore the necessity for initiatives related to health, such as educational campaigns in lowering biomass fuel consumption, particularly among vulnerable patients with COPD. Improved cooking techniques and alternative energy sources have the potential to significantly improve HRQoL. This study found that as COPD severity increases, HRQoL declines, with patients in GOLD stages 2, 3 and 4 having poorer HRQoL than those in GOLD stage 1. This finding aligns with previous studies conducted in the Netherlands.^{51 52} Based on these findings, subsequent initiatives should concentrate on targeted activities and plans to improve HRQoL, especially among patients at the severe and very severe GOLD stage.

The patients with comorbidities reported poorer HRQoL than those who have no comorbidities. As previous studies demonstrated, the presence of comorbidities negatively affects the HRQoL of patients with COPD. This finding aligns with previous studies from Sweden and Nepal,^{17 53} Spain⁵⁴ and a systematic review.⁵⁵ The increased complexity of the treatment regimen in the presence of comorbidities could lead to increased pill burden and polypharmacy, which may affect the HRQoL of patients with COPD, due to the fact that comorbid conditions may demand healthcare providers’ special attention.

This study established that patients with COPD who experienced more frequent hospitalisations have poor HRQoL compared with those with fewer hospitalisations. This finding suggests that recurrent hospitalisations may reflect more severe COPD, uncontrolled and greater symptom burdens, which negatively affect HRQoL. A comparable result has been reported in previous studies.^{56 57} Possibly attributable to the cumulative impact of disease severity, functional decline, psychological distress and socioeconomic burden associated with repeated hospitalisations. Therefore, prioritise preventive care, optimised pharmacotherapy, pulmonary rehabilitation and psychosocial support alongside community-based interventions to reduce hospitalisations and to enhance HRQoL.

Similarly, patients who were prescribed a greater number of medications experienced poorer HRQoL than those with a fewer number of prescribed medications. These results are consistent with earlier studies in the UK^{58 59} and in Greece.⁶⁰ An increased pill burden and their side effects may complicate medication management, as well as psychological effects, decreasing the overall HRQoL of patients with COPD. It suggests the need to prioritise regular medication evaluations, simplified treatment regimens, patient education and psychosocial support. Integrating community pharmacy services with multidisciplinary care can minimise pill load, promote adherence and improve overall HRQoL in patients with COPD.

Patients with low and moderate adherence experience poorer HRQoL than those with high adherence, consistent with results from previous studies.⁶¹ Moreover, studies from Iran support the result of this study. Patients with COPD who do not adhere to their medication experience worsening symptoms, frequent hospitalisation, psychological impacts, reduced functional status and a cumulative decrease in HRQoL. This result indicates the necessity of the use of combination inhalers with once-daily frequency, which can reduce treatment complexity while improving medication adherence. Additionally, patient education programmes focused on inhaler technique, symptom detection and self-management methods are crucial for empowering patients and improving HRQoL. Several limitations of this study should be acknowledged. First, reliance on self-reported questionnaires may cause recall bias. Second, being hospital-based limits the applicability of our findings to other populations. Lastly, the cross-sectional design prevents us from establishing causal relationships between associated factors and HRQoL.

Conclusion and recommendation

This study reported that HRQoL among patients with COPD in Ethiopia was severely deteriorated, assessed using the validated CAT-Am. Older age, poor social support, biomass fuel exposure, advanced GOLD stages, the presence of comorbidities, frequent hospitalisations, an increased number of prescribed medications, and low and moderate medication adherence were associated with poor HRQoL. These findings point out the need for multidisciplinary COPD care strategies that prioritise personalised medication, medication adherence support and regular follow-up. Future research could need to be conducted by using a comparator group, which would provide a better idea about the extent of the effect on the HRQoL of patients with COPD.

Data availability statement

Data are available upon reasonable request.