Clustering of Unhealthy Lifestyle Behaviors is Associated with a Low Adherence to Recommended Preventive Practices Among COPD Patients in Spain

Abstract

Aims: To analyze clustering of unhealthy lifestyle behavior and its relationship with non-adherence to recommended clinical preventive care services among Spanish COPD patients. Methods: Cross-sectional study including 2,575 COPD subjects from the 2006 Spanish National Health Survey (NHS) and 2009 European Health Survey for Spain (EHISS). Subjects were asked about the following recommended preventive practices: uptake of blood pressure (BP) measurement, lipid profile, influenza vaccination and dental examination. Lifestyle behaviors included: smoking status, physical activity, alcohol consumption and obesity. Logistic regression models were built to assess the association between clustering of unhealthy lifestyle and the uptake of preventive activities. Results: Blood pressure measurement in the previous 6 months and a blood lipid test in the last year had not been taken by 11.74% and 23.26% of the subjects, respectively, in 2006 NHS and by 11.16% and 16.33% of the subjects, respectively, in EHISS 2009. Then, 36.36% percent had not been vaccinated and 70.61% had not received dental examination in 2006 NHS and these percentages decreased to 27.33% and 66.22%, respectively, in 2009 EHISS. A higher number of unhealthy lifestyle behaviors increased the probability of not being vaccinated and not having a dental examination. Clustering of unhealthy lifestyle behaviors is linearly associated with a greater number of preventive measures unfulfilled. Conclusions: Compliance with healthy lifestyles and adherence to recommended clinical preventive services is under desirable levels among Spanish COPD patients. Patients with lifestyles considered as “worse” are those who also have lower uptake of recommended preventive activities.

Keywords :

• alcohol consumption
• blood pressure control
• COPD
• dental care
• epidemiology
• food habits
• influenza vaccine
• lifestyle
• lipid profiles
• national health surveys
• physical activity
• preventive medicine
• smoking

Introduction

Chronic obstructive pulmonary disease (COPD) is a frequent preventable and treatable lung disease. It is one of the most prevalent and debilitating diseases in adults worldwide and generates large direct as well as indirect costs (1). Latest estimations in Spain, using the GOLD criteria, set COPD prevalence in 10.2% in individuals between 40 and 80 years of age (2). In addition, current data suggest that COPD mortality is increasing, and by 2030, is expected to be the fourth-leading cause of death and the seventh-leading cause of loss of disability-adjusted life years (3).

Clinical guidelines for the management of COPD patients have made care recommendations for treatment of COPD. General measures should be considered in any COPD patient comprise smoking cessation, influenza vaccination, regular physical activity, proper nutrition and assessment and treatment of co-morbidities (1,4). As reported by previous studies (5,6), cardiovascular risk factors, such as arterial hypertension and lipid metabolism disorders, are among the most prevalent diseases in COPD patients, so that these individuals should tightly control blood pressure and blood lipid levels, in order to prevent acute complications and reduce the risk of long-term complications. Moreover, given that previous studies have detected an association between COPD and periodontal disease, probably as a result of exposure to tobacco smoke (7,8), it is important to perform a dental examination to these patients, at least annually.

Despite the recommendations of the clinical guidelines on the management of COPD, their implementation in clinical practice is low (9). Even when being aware of having a chronic respiratory disease and perceiving their health worse than the rest of the population, persons with COPD still practice certain unfavorable behaviors. In fact it has been shown that the prevalence of healthy behaviors is less than optimal regarding some practice, such as smoking, physical activity and diet. It has been demonstrated that unhealthy lifestyle behaviors could be associated with progression and worse outcome of COPD (10).

Clustering of unhealthy lifestyle behaviors, such as tobacco smoking, hazardous alcohol drinking, sedentary lifestyle and unbalanced diet have been found to be linked with poor adherence to clinical preventive recommendations in the Spanish general population (11), but to our knowledge there is no study about this issue among COPD patients.

The Spanish Health System provides universal coverage and patients enter the health-care system mainly through primary care settings. Patients with COPD are included in health care protocols that include contact with a health care provider (general practitioner, and/or community nurse). All recommended clinical preventive services (blood pressure check-up, lipid profile, blood glucose levels monitoring  .  .  .), except dental care, are provided free of charge by the national health system. Despite universal coverage, an increasing percentage of the population also has some kind of private health care insurance coverage. But this private care insurance mainly covers those medical care services with higher cost/benefit ratio. Thus, primary care and preventive services are mostly provided by the public health care system.

The aims of this study were: a) to describe and analyze the adherence to selected clinical preventive care services (blood pressure and lipid profile check-ups, influenza vaccination and dental care), and prevalence of four unhealthy lifestyle behaviors (smoking, sedentariness, alcohol consumption, and obesity) among Spanish COPD patients; b) to assess the association between the degree of clustering of unhealthy lifestyle behaviors and non-adherence to preventive clinical practices.

Subject, material and methods

Study population

This study was undertaken using individualized data drawn from the 2006 National Health Surveys (NHS) and the 2009 European Health Interview Survey (EHISS) for Spain. These surveys are carried out by the Ministry of Health & Consumer Affairs and the National Statistics Institute and covers a representative sample of Spain's non-institutionalized population. Details of NHS and EHS methodologies are described elsewhere (12–15).

For study purposes, a total of 35,415 subjects aged over 40 years were selected, 20,060 from the NHS, and 15,355 from the ENS 2009. We identified individuals suffering COPD (chronic bronchitis or emphysema) as those that answered “yes” to the question, “Has your doctor told you that you are currently suffering from chronic bronchitis or emphysema?”

COPD patients were asked about the clinical preventive care services delivered by their healthcare providers, including blood pressure measurement in the last 6 months, lipid profile and dental examination in the last year, and having received a flu shot during the latest campaign. Several lifestyle behaviors, including smoking status, physical activity, alcohol consumption and obesity, were also assessed by the questionnaire. Tobacco use was categorized as current smokers and non/ex-smokers. Subjects were classified as sedentary if they acknowledged engaging in no leisure-time physical activity. Alcohol consumption was measured using answer to the question “Have you consumed any alcoholic drink in the last 2 weeks?” An affirmative answer to this question was considered an unhealthy behavior. Moreover, the body mass index (BMI) was calculated from the self-reported body weight and height. Finding obesity (BMI ≥ 30 mg/kg²) was considered an unhealthy lifestyle behavior.

The following were analyzed as independent variables: a) sociodemographic characteristics: age (40–59 years, and ≥ 60 years), sex, educational level (no studies, primary studies, secondary or more studies), marital status (unpaired, married or with a partner) and monthly income (< 850 Ä; 850–1400 Ä and > 1400 Ä); b) self-rated health: based on the answer of respondents rating their general health over the previous year on a 5-point scale ranging from ‘very good’ to ‘very poor.’ We merged them for analysis in two categories: very good/good and fair/poor/very poor.

We also collected the number of medical doctor diagnoses of co-morbid chronic conditions including: diabetes, high blood pressure, asthma, heart disease, myocardial infarction, cancer, arthritis and stroke. We analyzed the number of co-morbid diseases in three categories, namely: “None,” “One” and “Two or more.”

Statistical analysis

We estimated the prevalence of unhealthy lifestyle behaviors and non-adherence to clinical practices among COPD patients for each of the surveys used (2006 NHS and 2009 EHISS). The prevalences were described for each level of independent variables. The differences between the 2006 NHS and 2009 EHISS prevalences were assessed using the chi-square test. We built four logistic regression models, one for each of the four clinical preventive activities studied, using as main independent variable the number of unhealthy lifestyle behaviors (none to 4). Because very few subjects had all the unhealthy lifestyle behaviors, so 3 and 4 categories were merged into a “3 or more” category. The models were conducted including the COPD patients from both surveys and adjusting by age, sex, education, monthly income, self-rated health, and the year of survey. Odds ratio and 95% CI for each level were estimated using “none” as the reference category.

Last, we used multinomial logistic regression to examine the association between number of non-completed preventive clinical activities and number of unhealthy lifestyle behaviors. The variables included in the multivariate models were those that yield significant results in the bivariate analysis or were considered relevant according to the reviewed literature. The model was adjusted by all the independent variables used in the investigation.

The estimates were made using the “svy” (survey command) functions of the STATA software v10.0, which allowed us to incorporate the study design and weights in statistical analysis. Statistical significance was established at p < 0.05 (two-tailed p values).

As this investigation was conducted on unidentified public-use databases, it was not necessary to have the approval of an ethics committee according to the ­Spanish legislation.

Results

From 35,415 subjects aged > 40 years included in the 2006 NHS and 2009 EHISS, a total of 2,575 (7.2%) were classified as COPD sufferers. The prevalence rose from 6.6% (95% CI 6.3–6.9) to 8.2% (95% CI 7.7–8.6) from 2006 to 2009 (p < 0.05). Mean age was 67.9 years (SD 12.3) in 2006 and 67.5 year (SD 13.4) in 2009 (p > 0.05).

Prevalence of each lifestyle behavior analyzed according to sociodemographic variables and self-rated health adjusted by age and sex is shown in Table 1. In 2006 NHS, the most prevalent unhealthy behavior was alcohol consumption, followed by sedentary lifestyle, 45.4% and 44.8%, respectively. A higher proportion of males smoked and drank any amount of alcohol in the 2006 and 2009 surveys, while sedentariness was more prevalent among women in the 2006 NHS.

Table 1.   Prevalence of selected unhealthy behaviours according to sociodemographic variables and self-rated health among Spanish adults with COPD

	Smoking habit				Alcohol consumption				No exercise				BMI ≥ 30 kg/m^2
	2006		2009		2006		2009		2006		2009		2006		2009
	N	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%
Age
40–59 years	150	44.12%	156	43.82%	179*	52.65%	110	32.54%	157	46.18%	184	51.69%	81	25.55%	94	28.06%
≥ 60 years	109	11.12%	103	11.46%	421*	42.96%	215	26.64%	435*	44.39%	667	74.19%	213	28.48%	236	31.05%
Sex
Female	114	15.88%	94	14.24%	223	31.06%	74	12.17%	350*	48.75%	420	63.64%	155	28.97%	182	33.09%
Male	145	24.09%	165	27.73%	377*	62.62%	251	46.74%	242*	40.20%	431	72.44%	139	26.23%	148	27.16%
Marital status
Unpaired	108	19.71%	115	20.57%	211*	38.50%	116	23.20%	243*	44.34%	385	68.87%	109	26.46%	145	31.59%
Married or with a partner	150	19.51%	144	20.69%	388*	50.46%	209	32.40%	347*	45.12%	466	66.95%	185	28.37%	185	29.09%
Educational level
No studies	40	9.48%	56	10.69%	169*	40.05%	95	20.52%	220*	52.13%	385	73.47%	93	31.96%	149	35.82%
Primary studies	108	18.37%	81	21.49%	272*	46.26%	113	32.75%	245*	41.67%	249	66.05%	144	29.33%	104	29.89%
Secondary or more studies	111	36.39%	122	34.46%	159*	52.13%	117	34.72%	123*	40.33%	217	61.30%	56	20.07%	77	23.26%
Monthly income, €
< 850	92	15.01%	57	14.81%	260*	42.41%	83	23.38%	265*	43.23%	266	69.09%	143	30.23%	92	29.11%
850–1400	53	22.46%	69	21.17%	113*	47.88%	80	26.58%	108*	45.76%	224	68.71%	59*	30.57%	89	31.01%
> 1400	92	27.79%	96	25.00%	170*	51.36%	123	35.04%	152*	45.92%	246	64.06%	67	22.87%	108	30.42%
Self-rated health
Good	78	27.96%	93	28.53%	162*	58.06%	110	35.83%	91*	32.62%	182	55.83%	50	21.19%	59	19.80%
Poor	181	17.39%	166	17.87%	438*	42.07%	215	25.66%	501*	48.13%	669	72.01%	244*	29.43%	271	34.00%
Chronic diseases
None	96	26.89%	113	29.89%	196*	54.90%	131	36.39%	146*	40.90%	226	59.79%	65	22.41%	73	21.16%
1	112	22.76%	73	17.94%	235*	47.76%	115	30.59%	206*	41.87%	276	67.81%	105	25.80%	98	27.07%
≥ 2	51*	10.83%	73	15.53%	169*	35.88%	79	19.32%	240*	50.96%	349	74.26%	124*	33.70%	159	40.98%
Total	259	19.62%	259	20.64%	600*	45.45%	325	28.38%	592*	44.85%	851	67.81%	294	27.61%	330	30.14%

*Significant associations 2006–2009, p < 0.05.

Results from the 2006 NHS and 2009 EHISS.

By comparing the 2006 NHS and the 2009 EHISS surveys, we appreciate a significant increase in sedentariness (44.8% vs. 67.8%, p < 0.05) and a decrease in the alcohol consumption (45.4% vs. 28.3%, p < 0.05). By contrast, there were no significant differences between the two surveys in smoking habits (19.6% vs. 20.6%,) or in the prevalence of obesity (27.6% vs. 30.1%).

Prevalences of non-adherence to selected preventive clinical practices according to sociodemografic variables and self-rated health are shown in Table 2. In 2006 NHS, most COPD patients (70.6%) had not visited their dentist during the previous year and 36.36% were not vaccinated against influenza, but these unhealthy behaviors were significantly reduced in the 2009 EHISS. Blood pressure measurement in the previous 6 months and blood lipid test in the last year had not been taken by 11.7% and 23.2% of the subjects, respectively, in 2006 NHS and by 11.1% and 16.3% of the subjects, respectively, in EHISS 2009. Analysis by age group revealed that the adherence to all the clinical services increased with age except for dental care, which decreased. Males were vaccinated less frequently than females.

Table 2.   Prevalence of nonadherence to selected preventive clinical practices according to sociodemographic variables and self-rated health among Spanish adults with COPD

	No influenza vaccine last season				No blood pressure check-up last year				No lipid profile last year				No dental examination last year
	2006		2009		2006		2009		2006		2009		2006		2009
	n	%	n	%	n	%	n	%	n	%	n	%	n	%	n	%
Age
40–59 years	227*	66.76%	196	55.06%	68	20.00%	69	19.38%	94*	27.65%	75	21.07%	202	59.41%	207	58.15%
≥ 60 years	253*	25.82%	147	16.35%	87	8.88%	71	7.90%	213*	21.73%	130	14.46%	730*	74.49%	624	69.41%
Sex
Female	288*	40.11%	186	28.18%	95*	13.23%	59	8.94%	166*	23.12%	97	14.70%	485*	67.55%	413	62.58%
Male	192*	31.89%	157	26.39%	60*	9.97%	81	13.61%	141*	23.42%	108	18.15%	447	74.25%	418	70.25%
Marital status
Unpaired	199*	36.31%	153	27.37%	68	12.41%	65	11.63%	142*	25.91%	95	16.99%	398	72.63%	378	67.62%
Married or with a partner	279*	36.28%	190	27.30%	85	11.05%	75	10.78%	163*	21.20%	110	15.80%	532	69.18%	453	65.09%
Educational level
No studies	100*	23.70%	87	16.60%	35	8.29%	50	9.54%	94*	22.27%	81	15.46%	343*	81.28%	391	74.62%
Primary studies	209	35.54%	113	29.97%	70	11.90%	45	11.94%	135*	22.96%	59	15.65%	423	71.94%	254	67.37%
Secondary or more studies	167*	54.75%	143	40.40%	47	15.41%	45	12.71%	75*	24.59%	65	18.36%	164	53.77%	186	52.54%
Monthly income, €
< 850	184*	30.02%	81	21.04%	60	9.79%	51	13.25%	137	22.35%	70	18.18%	460	75.04%	282	73.25%
850–1400	92*	38.98%	95	29.14%	26	11.02%	30	9.20%	55	23.31%	56	17.18%	163	69.07%	222	68.10%
> 1400	153*	46.22%	117	30.47%	48	14.50%	41	10.68%	80*	24.17%	50	13.02%	215*	64.95%	213	55.47%
Self-rated health
Good	136*	48.75%	129	39.57%	65	23.30%	58	17.79%	86*	30.82%	77	23.62%	188*	67.38%	194	59.51%
Poor	344*	33.05%	214	23.04%	90	8.65%	82	8.83%	221*	21.23%	128	13.78%	744	71.47%	637	68.57%
Chronic diseases
None	167*	46.78%	134	35.45%	61	17.09%	62	16.40%	109*	30.53%	83	21.96%	247	69.19%	238	62.96%
1	188*	38.21%	118	28.99%	63	12.80%	55	13.51%	129*	26.22%	79	19.41%	350	71.14%	275	67.57%
≥ 2	125*	26.54%	91	19.36%	31	6.58%	23	4.89%	69*	14.65%	43	9.15%	335	71.13%	318	67.66%
Total	480*	36.36%	343	27.33%	155	11.74%	140	11.16%	307*	23.26%	205	16.33%	932*	70.61%	831	66.22%

*Significant associations 2006–2009, p < 0.05.

Results from the 2006 NHS and 2009 EHISS.

Table 3 shows the association between the number of unhealthy behaviors and non-adherence to each of the selected clinical preventive health practices. After adjusting by covariates a positive dose–response relationship was observed between the number of unhealthy behaviors and no influenza vaccination in the last season and no dental examination in the last year (p < 0.05). When compared with those with none of these behaviors, subjects with three or four had a 1.63-fold (95% CI 1.06–2.50) greater likelihood of not having received a flu shot during the latest campaign.

Table 3.   Association between number of unhealthy behaviours and nonadherence to selected clinical preventive practices among Spanish adults with COPD

	No infuenza vaccine last season			No blood pressure check-up last year			No lipid profile last year			No dental examination last year
Number unhealthy Behaviors	n (%)		OR (95% CI)	n (%)		OR (95% CI)	n (%)		OR (95% CI)	n (%)		OR (95% CI)
None	162	19.68	1	66	22.37	1	123	24.02	1	365	20.70	1
One	354	43.01	1.19 (0.92–1.55)	117	39.66	0.86 (0.60–1.23)	197	38.48	0.77 (0.58–1.02)	825	46.80	1.35 (1.06–1.72)*
Two	231	28.07	1.32 (0.99–1.76)	91	30.85	1.07 (0.73–1.57)	154	30.08	1.15 (0.85–1.56)	450	25.52	1.39 (1.06–1.83)*
Three or four	76	9.23	1.63 (1.06–2.50)*	21	7.12	0.74 (0.40–1.36)	38	7.42	1.05 (0.66–1.68)	123	6.98	1.27 (0.85–1.90)
P-value for linear trend	< 0.05			NS			NS			< 0.05

NS indicates not significant.

^aOdds ratio (95% CI) estimated using logistic regression, adjusted for age, sex, education level, monthly income, and self-rated health.

*Significant association, I < 0.05.

Results from the 2006 NHS and 2009 EHISS.

Similar results were obtained for not having received a dental examination in the previous year. The presence of two versus none unhealthy behavior was significantly associated with no adherence to this check-up (OR 1.39; 95% CI 1.06–1.83). No association has been found for not having had a blood pressure check-up in the last 6 months and for not having received a lipid profile in the previous year.

Figure 1 shows the adjusted odds ratios (95% CI) obtained by multinomial logistic regression for non-adherence to one, two or three-four preventive clinical services practices for each level of clustering of unhealthy lifestyle behavior. Within each level of clustering of non-adherence to preventive measures, association is stronger with each added unhealthy behavior, though linear trend was not statistically significant. Moreover, a higher number of unhealthy lifestyle behaviors were associated with a higher number of preventive measures unfulfilled. The association was statistically significant for two unhealthy behaviors with three non- adherences to preventive services, and for three-four unhealthy behaviors with two and three non-adherences. This means that a COPD patient who had 3–4 unhealthy behaviors had 2.13 (CI 95% 1.07–4.25) times more probability of not having adhered to 3-4 preventive clinical practices when compared to a subject who had none of the unhealthy behaviors studied.

Figure 1.   Odds ratio (95% CI) for nonadherence to one, two, and three to four preventive recommendations of COPD subjects with one, two or three to four unhealthy behavioral lifestyle practices compared to those with none of them. Results from the 2006 NHS and 2009 EHISS. ♦ Odds ratio. * Significant association, p < 0.05.

Discussion

Our results suggest that clustering of lifestyle unhealthy behaviors is associated with a low adherence to recommendations for influenza vaccination and dental examination in the last year when individually considered, but not with blood pressure and blood lipids checkups. Moreover, a higher number of unhealthy behaviors increase the probability of having a lower number of clinical preventive recommendations fulfilled.

Other studies conducted in Spain among COPD patients showed prevalences similar to ours for current smoking (16–18), alcohol consumption (19,20) and physical exercise (20,21). Previous studies have also detected a high prevalence of obesity in COPD patients in Spain (5,22).

We agree with other authors (10, 23–26) that the uptake of clinical preventive services among COPD patients included in our study is suboptimal. Between 16–17% of COPD patients did not comply with a blood pressure check-up within the last 6 months. Non-adherence to a lipid profile during the last year in our study is also high. Almost 40% of adults with COPD in the 2006 NHS and 27.33% in 2009 EHISS were not vaccinated against influenza in the previous campaign. Higher-educated and wealthier COPD patients are less likely to be vaccinated while coverage is higher among those with 2 or more chronic diseases and perceiving their health as poor.

In addition, vaccine coverage was significantly low among those bellow 60 years and among women. On the other hand, about 70% of adults with COPD had not undertaken a dental examination in the previous year. Except for dental examination, younger COPD adults have a lower uptake of the preventive recommendations analyzed. This is particularly worrying, since they have a greater lifetime risk of developing complications.

Having one or two unhealthy lifestyle behaviors increased the probability of not having undertaken a dental examination in the previous year. This preventive clinical practice was associated to older age, lower educational level and lower monthly income group, suggesting the influence of socioeconomic status. Previous studies showed that COPD care is often governed by income and insurance coverage (27,28). Thus, lack of financial coverage could explain the poor uptake of this measure among the oldest and the lower income groups of our population, since the dental exam is the only preventive activity not delivered by Spanish National Health System. On the other hand, having three or four unhealthy lifestyle behaviors increased the probability of not having received flu vaccine in the previous campaign.

Our results show that after adjusting for monthly income and educational level as proxies of socioeconomic status, and by self-rated health, association between both cluster remains. Furthermore, our results suggest that there is a trend, although not statistically significant, for less preventive measures fulfilled with any unhealthy behavior added to the cluster. Cluster of unhealthy behavioral risk factors has been previously linked to lower uptake of clinical preventive services in general population (11). However, to our knowledge, this is the first time this association is demonstrated among COPD patients in Spain. This conclusion is relevant since subjects at highest risk (those with the greatest number of unhealthy behaviors) are less likely to receive the recommended preventive care clinical practices even though they are those who would obtain the maximum benefit.

Our results also suggest that individuals with less healthy behaviors would also be less aware of other risk factors and therefore less likely to engage in clinical preventive services. But other organizational variables that could hamper accessibility to preventive care services should also be considered. For example in a study conducted among Spanish medical practicioners about knowledge and barriers for prevention and health promotion activities, showed that almost 52.4% of them considered, “Carrying out of prevention and health promotion activities is difficult,” and 94% perceived “Heavy work load and lack of time” as a barrier for implementing health promotion and preventive activities. Other perceived barriers were “Patients’ accesibility” (20%), Lack of clarity on which professional in primary care is responsible” (21%), and “Insufficient personal training in prevention and health promotion” (16%) (29).

Another recent study that explored the views of medical practicioners in hospital and general practice to implementation of several high-evidence care recommendations for patients with COPD identified four main issues that impacted on implementation: clarity of the doctor´s role, use of persuasive communication, nature of the behavior change required and awareness and support strategies available at multiple levels (25). Low implementation of evidence-based care recommendations in COPD patients translates into poorer outcomes for patients, and greater cost to the health care system (30).

The strengths of our study include its large, population based sample and our ability to control for a broad range of important covariates, including demographic, socioeconomic factors and self-rated health. However, there are a number of possible study limitations. First, our definition of COPD was based on self-reported physician-diagnoses of the disease, and did not rely on lung function tests. As such, there might be an issue of recall bias. However, this definition has been widely used in large international surveys (31,32), and has proved to be reasonably reliable (33). Second, another possible limitation of health surveys is that the use of unvalidated self-reported data on unhealthy lifestyle behaviors and preventive care recommendation fulfillment could entail a possible bias, due to recall errors or to the tendency of individuals to give socially desirable responses within interviews.

In fact, some studies pointed out that self-report can either underestimates or overestimates the prevalence of preventive care and behaviors. This, however, would bias the examined associations towards the null, so the differences are probably even greater than reported (34). Third, cross-sectional design make impossible to discard reverse causation, since clinical preventive activities may promote changes in health behaviors (positively or negatively). Nevertheless, our aim was not to establish a causal link but to assess a dose-response relationship between the number of unhealthy behaviors and the number of fulfilled preventive measures regardless its direction. Finally, the survey is possibly subject to selection bias, if participation in the survey is correlated with the dependent variables. The initial response rates to 2006 NHS and 2009 EHISS were 65% and 64%, respectively (35,36).

In conclusion, the adherence to recommended clinical preventives practices is suboptimal in patients with COPD in Spain. Moreover preventive services are provided neither equitably nor efficiently, since subjects with a unhealthier lifestyle behavior are less likely to receive them. Efforts to enhance healthy lifestyle behaviors among COPD patients are necessary. Programs encouraging preventive care should emphasize the need for preventive care regardless of age, general health status and severity of disease, countering possible perceptions that only seriously ill or old individuals need to receive these recommendations. Future research is needed to identify individual and organizational factors that allow interventions to reach these high-risk subjects minimizing the number of missed opportunities for delivery of educational and preventive healthcare for all subjects with COPD.

Declaration of Interest Statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.