Chronic obstructive pulmonary disease (COPD) is a major global health burden, affecting approximately 213 million people and causing around 3.7 million deaths in 2021, according to the Global Burden of Disease 2021 (GBD 2021) estimates and the WHO 2024 fact sheet (1, 2). Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a clinical state characterized by a rapid worsening of airway function and respiratory symptoms (3). It manifests as increased breathlessness, cough, sputum production, and sputum purulence, often requiring additional treatment (4). AECOPD are associated with poor prognosis, with hospitalization-related mortality rates reaching 15–30% within one year and up to 43% within two years, imposing a substantial financial burden on healthcare systems (5).

The most common triggers for AECOPD are respiratory infections (viral and bacterial), which account for approximately 70–80% of exacerbations (6). Other contributing factors include air pollution, non-adherence to maintenance therapy, and comorbidities. Studies in Chinese populations have reported a high recurrence rate of AECOPD, with approximately 20% of patients requiring re-hospitalization within 30 days and up to 60% experiencing at least one exacerbation within a year after their first event (7). A systematic review and meta-analysis reported AECOPD readmission rates of 11, 17, 17, 30, and 37% at 30, 60, 90, 180, and 365 days post-discharge, respectively (8). Self-management plays a crucial role in preventing AECOPD onset and progression, as early recognition of symptoms and prompt action can reduce hospitalization rates by up to 40% and significantly improve quality of life (7).

The Knowledge, Attitude, and Practice (KAP) framework provides a structured methodology for understanding patient behaviors and implementing targeted interventions. According to KAP theory, behavior change follows a sequential process: knowledge acquisition leads to attitude formation, which ultimately results in practice modification. This framework is particularly relevant as patient understanding and self-management practices significantly influence exacerbation outcomes (9). Investigating COPD patients’ KAP regarding AECOPD is crucial for identifying gaps in disease understanding, optimizing self-management strategies, and ultimately reducing exacerbation-related morbidity and healthcare burden.

Current KAP research on COPD patients has primarily focused on general disease knowledge (10), inhaler technique (11), smoking cessation (12), and pulmonary rehabilitation (13). Several studies have investigated patients’ overall understanding of COPD, but few have specifically examined patients’ knowledge, attitudes, and practices regarding AECOPD management. Therefore, this study aims to comprehensively assess the knowledge, attitudes, and practices regarding AECOPD among Chinese COPD patients.

The results of this study indicated that patients with COPD exhibited inadequate knowledge, yet generally positive attitudes and proactive practices regarding AECOPD. The observed positive correlations among knowledge, attitudes, and practices suggest that enhancing knowledge may improve both attitudes and self-management practices. Therefore, targeted educational interventions should be implemented to increase COPD patients’ understanding of AECOPD, particularly among older individuals and lower dyspnea scales.

Our assessment of participants’ KAP scores revealed notable disparities across domains, with knowledge scores (7.25 ± 4.43, representing only 27.9% of the maximum possible score) being particularly low compared to attitude (36.91 ± 4.56, 67.1% of maximum) and practice (30.59 ± 3.76, 61.2% of maximum) scores. This pattern differs from findings in other KAP studies among COPD patients. A study conducted in urban China reported a higher knowledge rate (64.7%) but lower levels of proactive practices, while a Spanish survey identified similarly low knowledge with less favorable attitudes and poor self-management behaviors (9, 24). For instance, a study (9) reported higher knowledge levels (64.7% of maximum possible score) among urban Chinese COPD patients, while Hernandez et al. (24) found comparable knowledge deficits (33.2% of maximum) but lower practice scores (48.5% of maximum) in a Spanish cohort. This phenomenon of ‘practice-knowledge discordance’ has been observed in other chronic disease management studies (25), where patients develop functional management strategies through experience rather than formal education. The influence of social desirability bias may have contributed to the discrepancy between high reported attitudes and practices and low knowledge scores, as participants might have tended to give socially acceptable responses. However, this bias alone may not fully explain the pattern. Some participants may have formed habitual self-management behaviors through long-term interaction with healthcare professionals or repetitive exposure to community health messages, even in the absence of formal disease knowledge. The correlation analysis results demonstrated significant positive associations between knowledge, attitudes, and practices, indicating the interconnected nature of these domains in COPD management. Previous research has indicated that knowledge plays a fundamental role in shaping both attitudes and health-related behaviors (26, 27), yet many COPD patients in this study demonstrated a lack of awareness about fundamental aspects of their condition, particularly regarding triggers of exacerbations, appropriate medication use, and preventive strategies. Similar knowledge deficits have been reported in multiple COPD populations globally, including a study (28) found that Spanish COPD patients correctly answered only 35% of disease knowledge questions. SEM further revealed that knowledge not only directly influenced practice but also exerted an indirect effect through attitude, aligning with the theoretical framework of health behavior models that emphasize the cascading impact of knowledge on subsequent behavioral outcomes (29, 30).

The multivariate regression analysis identified several demographic and clinical factors significantly associated with knowledge, attitudes, and practices. Older patients exhibited significantly lower knowledge levels, a trend that has been widely reported in chronic disease populations, potentially due to cognitive decline, limited access to digital health resources, and lower health literacy (31, 32). The association between severe dyspnea and higher knowledge levels suggests that symptom burden may drive greater engagement with health information, as patients experiencing more distressing symptoms are more likely to seek medical advice or educational resources. However, the observed disparities between urban and rural populations indicate that access to structured educational programs remains uneven. Urban residents demonstrated significantly higher attitude and practice scores, a trend that has been documented in studies examining healthcare disparities, where urban populations benefit from greater healthcare accessibility, more frequent provider interactions, and higher exposure to public health campaigns (33, 34).

Our analysis of attitude scores and their determinants revealed complex patterns across different patient subgroups. While most patients expressed generally positive perspectives on COPD management, a significant proportion exhibited uncertainty about the effectiveness of preventive measures. The finding that patients with a longer disease duration were less likely to have a positive attitude suggests that sustained disease burden may lead to treatment fatigue and diminished motivation for long-term adherence, a phenomenon commonly observed in chronic illness management (35, 36). The association between symptom severity and less favorable attitudes may also reflect the psychological burden of COPD, as patients with more severe dyspnea often experience higher levels of anxiety and depression, which can negatively impact their perceptions of disease control and self-efficacy (37, 38). These results are in line with studies on other chronic respiratory diseases, where patients experiencing higher symptom burden often report greater frustration with disease management and reduced trust in treatment efficacy (39, 40).

The multivariate analysis of practice scores highlighted the significant impact of knowledge, attitudes, and sociodemographic factors of income and smoking status on patients’ self-management behaviors. The findings on practice further underscore the importance of knowledge and attitude in shaping self-management behaviors. Patients with higher knowledge and attitude scores were more likely to engage in proactive practices, supporting the widely established relationship between health literacy and adherence to treatment recommendations (41, 42). However, significant disparities were observed based on socioeconomic status and smoking history. Patients with higher income levels were more likely to engage in preventive behaviors, which aligns with existing literature demonstrating that financial security facilitates better access to healthcare resources, medications, and follow-up visits (43, 44). Meanwhile, the significantly lower practice scores among current smokers highlight the persistent challenge of smoking cessation in COPD management. Previous studies have indicated that current smokers are less likely to adhere to treatment regimens and engage in preventive behaviors, potentially due to lower risk perception and reduced motivation to modify lifestyle habits (45, 46).

Detailed examination of individual knowledge, attitude, and practice items in the Supplementary material revealed specific areas of concern that require targeted intervention. The Supplementary material further illustrate the extent of knowledge gaps among COPD patients. A particularly concerning finding was the lack of knowledge regarding proper inhaler technique and medication management during acute exacerbations. Only 18.20% of participants reported being “very familiar” with the correct use of inhalation devices, including crucial techniques such as complete exhalation before inhalation, proper inhalation technique, breath-holding, and mouth rinsing after use. Similarly, only 5.62% were familiar with the necessity of medication under a doctor’s supervision during acute exacerbations and the possibility of hospitalization in severe cases. These findings align with previous research highlighting widespread deficiencies in inhaler technique knowledge and practice among COPD patients. For instance, one study found that 79% of COPD patients made at least one error in inhaler technique, with critical errors that significantly reduced drug delivery occurring in 28% of patients (11). Similarly, a systematic review reported that 50–80% of patients demonstrated incorrect inhaler technique, with errors persisting even after repeated instruction (47, 48). This is particularly problematic given that proper inhaler technique is essential for effective drug delivery to the airways, with studies showing that incorrect technique can reduce the amount of medication reaching the lungs by up to 50%, leading to poor symptom control and increased exacerbation rates (48). Moreover, the low awareness about proper medication management during exacerbations is concerning, as timely and appropriate medication adjustments under medical supervision are crucial for preventing exacerbation progression and reducing hospitalization risk. Previous research has demonstrated that delayed treatment or inappropriate self-medication during exacerbations can lead to prolonged recovery time and increased healthcare utilization (15, 16). A large proportion of respondents were unable to correctly identify key aspects of disease management, including medication use, monitoring tools, and preventive strategies. This is concerning given that previous research has shown that patients who are unaware of proper medication techniques, such as inhaler use, often experience poorer symptom control and increased exacerbation rates (47, 48). The lack of awareness about monitoring tools is particularly notable, as self-monitoring has been linked to improved outcomes in COPD management by enabling early intervention during exacerbations (49, 50). Similarly, the attitude data suggest that while most patients acknowledge the impact of COPD on their quality of life, many remain unconvinced about the effectiveness of proactive disease management strategies. The practice data further support this concern, with particularly low adherence to regular medical check-ups and vaccinations, both of which are crucial in preventing severe exacerbations. Studies in comparable populations have suggested that vaccine hesitancy remains a major issue in COPD management, often influenced by misinformation, lack of provider recommendation, and accessibility barriers (51, 52).

Based on our findings of inadequate knowledge despite positive attitudes and practices, a multifaceted intervention strategy is needed to address these gaps. Given the strong association between knowledge and practice, expanding patient education programs should be prioritized. Traditional education sessions in clinical settings have been shown to be effective but may not reach all patients, particularly those in rural areas. Digital health interventions, including mobile-based education programs, telehealth consultations, and interactive learning modules, have demonstrated success in improving disease literacy and self-management in similar populations (53, 54). Healthcare providers should also adopt a more structured approach to patient education by integrating regular reinforcement of key COPD management principles into routine consultations. Studies have shown that repeated exposure to health information enhances retention and long-term behavioral change, particularly in chronic disease populations (55, 56). Cognitive-behavioral therapy and structured counseling programs have been effective in improving treatment adherence and self-efficacy in patients with other chronic illnesses and should be considered as part of COPD care (57). Moreover, targeted interventions should focus on populations at higher risk of poor disease management, including older adults and those with lower socioeconomic status.

This study has several limitations. First, as a cross-sectional survey, it only captures associations rather than causal relationships, limiting the ability to infer the impact of knowledge and attitudes on practices over time. Second, the data were collected from a single hospital, which may restrict the generalizability of the findings to broader COPD populations with different healthcare access and socioeconomic backgrounds. Third, self-reported measures of knowledge, attitudes, and practices are subject to response bias, as participants may have overestimated or underestimated their actual understanding and behaviors.

In conclusion, COPD patients demonstrated inadequate knowledge but exhibited positive attitudes and proactive practices regarding AECOPD. The observed correlations between knowledge, attitudes, and practices suggest that improving patient knowledge may enhance both attitudes and self-management behaviors. Targeted educational interventions focusing on COPD management, particularly for older patients and those with less severe symptoms, may be beneficial in improving disease awareness and promoting better self-care practices. For future implementation, mobile-based education tools and telehealth consultations could be explored as accessible platforms in low-resource settings. Ultimately reducing the risk of AECOPD. Additionally, the use of convenience sampling may limit representativeness. The 60% threshold for KAP classification was adapted from previous studies but remains arbitrary.