Chronic Obstructive Pulmonary Disease (COPD) is prevalent worldwide. The World Health Organization has reported the disease as the third leading cause of death globally, causing 3.23 million deaths in 2019, with Over 80% occurring in low- and middle-income countries (LMIC). ¹ In Jordan, COPD has a prevalence rate of 6.5% in patients under 50 years of age and 37.5% in patients aged ≥70 years, which is much higher than the reported international prevalence rate, especially for the latter age group. ²

COPD causes persistent and progressive respiratory symptoms, including difficulty in breathing, cough, and thick viscous mucus secreted within the respiratory passages. It also exacerbates during physical exercise and exertion. ^{3 – 6} It is usually caused by prolonged exposure to dangerous chemicals and particles and by individual variables such as early experiences that affect lung development and heredity. Tobacco smoke exposure, indoor air pollution, occupational dust, gases, and chemicals all contribute significantly to the chance of developing COPD.

Early diagnosis and treatment, especially assistance for smoking cessation, are necessary to slow the progression of symptoms and minimize flare-ups. ⁷ As COPD advances, patients increasingly struggle to do routine everyday activities, frequently due to dyspnea. In addition, since the COVID-19 pandemic, there may be a significant financial burden because of the reduced workplace and home productivity and medical care costs. During flare-ups, patients with COPD may notice an increase in their symptoms which may require further treatment at home or admission to the hospital for emergency care, as severe flare-ups can be fatal. ⁷

There is an association between COPD and many other diseases, such as cardiovascular, lung cancer, osteoporosis, skeletal muscle, cachexia, gastrointestinal, metabolic, other respiratory illnesses, and mental health issues such as anxiety and depression. ⁸ The correlation between COPD symptom load and anxiety and depression is important, as the combination of these disorders can worsen the disease course, duration, and outcome. ⁹

Studies have shown that COPD negatively correlates with the Quality of Life (QoL), ^{10 – 17} and this correlation worsens as the severity increases. Kushwaha et al. (2020) reported “impaired” life processes and health-related quality of life among patients with COPD. ^{18 , 19}

In Jordan and in the Middle East region, there is a lack of national or regional studies about the extent of the COPD disease in the country and the service offered for these patients. Most studies and evidence come from developed countries. Also, available epidemiological data significantly underestimate the entire frequency of COPD because the disease is typically not identified until it is clinically evident and moderately progressed. ^{20 – 22} Furthermore, the causing and the exacerbating factors for COPD are also common in Jordan; for example, environmental toxins, pollutants, smoking habits, and occupational chemicals exposures that are trigger for respiratory illnesses have been reported to be much higher than the accepted international standards. ^{23 – 25}

A recent study in Jordan ²⁶ investigated uncertainty, anxiety, and the Health-Related Quality of life (HRQoL) among COPD patients and found higher levels of these variables among their study participants. Although important, the finding lacked details about these issues since the HRQoL was one variable measured in the study, among others.

COPD is a long-term, severe, and exhausting condition. Patients are highly dependent and frequent users of the healthcare services; therefore, their Quality of Life (QoL) is an important consideration to measure and improve. In addition, their QoL is expected to be highly influenced by the health care services they receive. In Jordan, the QoL of patients with COPD must be studied to devise interventions that can help patients cope with this disease and for healthcare systems to improve their services.

Therefore, this study will focus on QoL and assess its different domains such as physical, psychological, social interaction, and environmental. Additionally, this study will help identify the concerns of COPD patients about their QoL; and the main determinant factors affecting it.

The objective of this study is to assess chronic obstructive pulmonary disease patients’ quality of life and its related factors within the Jordanian population.

At present, Jordan has a high incidence of Pulmonary and Cardiovascular diseases. Unfortunately, the reality of the health care systems in this country is that they provide suboptimal services that cannot provide much-needed care and attention for these patients.

The results of this study demonstrated that perceived QoL among Jordanian patients is low and reflects a poor perception of QoL. Similar results were reported internationally and triggered interventions to improve patients’QoL. For example, studies in South korea and Portugal have shown that the HRQoL was impaired in patients with COPD and other respiratory illnesses, and it further deteriorated with increase in disease severity. ^{29 , 31}

The physical domain had the lowest perceived QoL. Several studies have also reported the physical environment among the domains with the lowest perceived QoL. ^{11 , 26 , 32} This domain relates mainly to the patients’ physical abilities to perform tasks, which were impaired due to shortness of breath and other symptoms of the disease. ³³ Therefore, it would be imperative that healthcare professionals focus a good portion of their efforts on mitigating the physical effects of COPD on their patients to improve their quality of life through pre-planned and targeted interventions.

The current study also found that COPD patients are experiencing severe negative emotions in the psychological domain, such as anxiety and depression. This has led to a decreased QoL; this was consistent with the study by Lim et al. (2017), ³⁴ who found that symptoms like anxiety and depression caused a lower level of QoL in COPD patients. A previous study in Jordan saw that the perceived QoL among COPD patients was highly related to feelings of uncertainty and anxiety. ²⁶ Those feelings might have heightened during the COVID-19 pandemic as fear and anxiety from infection, and severe course of illness peaked. ³⁵ Patients with COPD or similar complex and long-term conditions are vulnerable to mental health issues, ³⁵ yet in Jordan, they do not receive any form of psychological support interventions. The health system in Jordan focuses on physical health rather than mental or psychological health. Therefore, this seems to be a huge gap that needs to be addressed quickly by the healthcare service planners.

Medical treatment enables COPD patients to function in daily life; in Jordan, especially during the pandemic, there is the issue of medical treatment availability. This further contributes to the lowered QoL perception. Similarly, Ciążyńska et al. (2020) study reported the unavailability of medical treatment for COPD patients and how that severely impacts their perceptions of QoL. ¹²

This study showed that personal and sexual relationships in the social domain were among the patient’s second mean score level of perceived QoL. Kurpas and colleagues (2016) reported that social relationships increase the QoL because patients do not experience loneliness and lack support. ³⁶ However, participants in the study seem to be also struggling with assuming a regular social interaction and their personal and sexual relationships. COPD seems to have also affected this area of their life, resulting in lower perceptions of QoL. During the recent COVID19 pandemic, social interaction was limited, thus adding more challenges to COPD patients. Evidence indicated that the situation with COPD patients was worsening as many people refrained from visiting these patients to prevent COVID transmission; People were allowed to contact one another during Covid-19 by phone calls or internet. However, physical interaction was not allowed. ³⁷ In addition, poor sexual relations (as part of the social domain) lead to a decrease in the QoL for these patients due to some of the symptoms of the disease, which, in turn, may reduce the quality of their sexual relationships and thus their QoL. This finding was consistent with a review study conducted by Merghati-Khoei and her colleagues. ³⁸

When comparing the subgroups of the study, for example, those treated in private vs. governmental vs. educational hospitals, and those in different age groups, it was found that the QoL was different. Patients treated in private hospitals, who were non-smokers, unmarried, and employed have better QoL perceptions. These are all indicators of the main factors that may affect the perception of QoL for these patients in Jordan, probably internationally as well. ^{5 , 11 , 14 , 15 , 18 , 33 , 39} Therefore, these constitute reasonable goals for the healthcare service providers and planners to target to improve the QoL perceptions among patients with COPD.

This study assessed the current state of QoL of Jordanian patients with COPD and identified the factors that affect it. The results indicated that the perceived QoL of COPD patients in Jordan is low and requires immediate interventions. The goal of the interventions should be to improve the healthcare service provided for these patients and thus their perceived QoL. The areas that may be targeted to achieve this goal include: 1.

To give equal importance to the provision of a psychosocial and mental health support service to the patients.

This study collected data through a valid and reliable questionnaire and from an adequate sample size. While the data collected is useful, it may lack depth and details. A qualitative approach may have yielded more useful and in-depth data.

The study is well positioned to be generalizable to the Jordanian population. While it may not be generalizable beyond that, neighboring countries with the same economical, sociocultural and health system contexts may learn from the results of this study.

Enas Assaf & Angham Badarneh: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Original Draft Preparation; Ahmad Saifan & Nabeel Al-Yateem: Supervision, Writing – Final Draft Preparation, Writing – Review & Editing.