Search strategy and information source

A comprehensive systematic search was conducted across six electronic databases: MEDLINE (OVID), EMBASE (OVID), CINAHL (EBSCO), PsycINFO (OVID), Web of Science, and Scopus from their inception until November 2023. The search strategy was developed with assistance of an expert librarian. No restriction on publication date was applied. Forwards and backwards reference screening was performed, as well as searching grey literature (using Google Scholar and OpenGrey), to identify additional relevant papers. A full search strategy with key terms is included in the (S2 Table).

Eligibility criteria

The Sample, Phenomenon of Interest, Design, Evaluation, and Research Type (SPIDER) tool was used to frame the inclusion criteria [19].

Sample: People living with COPD who are from minority ethnic communities irrespective of their age, disease stage, and the presence of comorbidities.

Phenomenon of Interest: Uptake and adherence to treatment interventions of COPD including medication taking, pulmonary rehabilitation, smoking cessation, influenza vaccination, and use of long-term oxygen therapy (LTOT).

Design: Qualitative studies or mixed-method studies that included perspectives of people living with COPD towards treatment interventions (i.e., patient interviews or focus groups). Mixed-method studies will be eligible for inclusion only if sufficient qualitative data is provided in the publication or can be obtained from the authors. This review followed the seven steps of meta-ethnography, that was originally developed by Noblit and Hare [20]. These included: (1) getting started, (2) deciding what is relevant to the initial interest, (3) reading the studies, (4) determining how studies are related, (5) translating the studies into one another, (6) synthesising translations, and (7) expressing the synthesis.

Evaluation: Studies that investigated barriers to and/or enablers of adherence to treatment interventions of COPD amongst minority ethnic communities. Studies that examined variables such as physical activity, diet, exercise training, and maintenance without focusing on adherence to treatment interventions for COPD were excluded.

Research type: This meta-ethnography, as a form of qualitative evidence synthesis, only includes qualitative research. Where views of individuals from minority ethnic communities could not be independently extracted from that of other data reported, or corresponding authors could not provide data for the independent groups, the study was excluded. Additionally, Quantitative studies, systematic reviews, clinical trials, protocols, and conference abstracts were not considered. Papers written in languages other than English were also excluded due to the unavailability of translation services and time constraints within the scope of this project.

Study selection and screening

All identified articles were exported into EndNote 20.6 for initial screening, and to detect duplicates [21]. The titles and abstracts were initially screened by one reviewer (SA) according to the inclusion criteria. Eligible articles were then imported into Rayyan software [22] and distributed among five reviewers (SA, AKH, HN, AR-B, and MC) for independent full-text assessment. No disagreements arose between the authors.

Reading, data extraction, and quality appraisal

Two reviewers (SA and AR-B) carefully read the included studies to ensure familiarity with the data. A customised data extraction form was designed and used for data extraction across the included studies. Data extraction included information about the study and author details, country setting, study aims, participant demographics (age and sex), type of intervention, and study findings, including the main themes, original quotes, and/or explanations provided by the authors of primary studies. Quality appraisal was performed independently by SA and AR-B using the Critical Appraisal Skills Programme (CASP) for qualitative research [23]. No papers were excluded based on quality.

Analysis and interpretive synthesis

Meta-ethnography has begun to be used more widely in healthcare research, particularly when the researcher aims to conceptualise deeper understandings of patient experiences of certain illnesses and disease-management [24]. A meta-ethnographic approach, as a form of qualitative evidence synthesis, was chosen to understand the effect of ethnicity on adherence to treatment and to develop a concept that explains the barriers and facilitators of adherence to treatment interventions of COPD amongst individuals from minority ethnic communities.

Determining how studies are related. A table summarising the findings extracted from the primary studies was created, incorporating the concepts and metaphors developed by the original authors. This approach facilitated the exploration and comparison of the findings. Two reviewers (SA and AR-B) then revised how the concepts and metaphors are related through discussion (Step 4).

Translating the studies into one another. Reciprocal translation was used to develop third-order constructs. This approach involves a comparison of concepts and themes from study 1 to those extracted from study 2, then comparing the combined themes from these studies, with findings from study 3, and so on. This process continued until all included papers were synthesised, and the reviewers identified and grouped similar themes. Two reviewers (SA and AR-B) were independently involved in the translation phase; no disagreements arose between the two authors. (Step5)

Synthesising translations and expressing the synthesis. Third-order constructs (overall interpretations) were developed by carefully synthesising and analysing first-order constructs (i.e., participant quotations) and the second-order constructs (i.e., original study authors’ interpretations) (Steps 6 and 7). To adhere to recommendations for conducting meta-ethnographies, the authors of this study use the term ‘theme’ to describe the third-order construct, and sub-themes to describe third-order construct sub-themes [18]. The development of these overarching themes enables meta-ethnographies to delve further into a topic than a traditional systematic review and contribute new insights to literature [25].

Study characteristics

The publication dates of the included articles ranged between 2015 [26] to 2023 [27]. The studies were conducted in four countries; the US (n = 3) [27–29], the UK (n = 2) [30,31], Canada (n = 1) [26], and New Zealand (n = 1) [32]. Included articles reported various minority ethnic communities including Asian [30,31], Black [30], Māori [32], Hispanic [27–29], African American [27–29], and people from Chinese ethnicity living in Canada [26]. Three types of interventions for COPD treatment were explored by the included articles; pulmonary rehabilitation (n = 5), [27,29–32], smoking cessation (n = 1), [26,28], and a combination of smoking cessation and medication adherence (n = 1) [28]. No qualitative studies investigated the experiences of people from minority ethnic communities with long-term oxygen therapy and vaccinations. Further study characteristics are detailed in Table 1.

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Table 1. Characteristics of the included studies.

https://doi.org/10.1371/journal.pone.0318709.t001

Study quality

Quality assessment for the included studies was conducted by (SA and AR-B) using the Critical Appraisal Skills Programme (CASP) tool for qualitative research [23]. All the included articles met the criteria for clarity of research aims, consideration of ethical issues, data collection, and reporting of study results [26–32]. However, four of the studies lacked sufficient details regarding the relationship between the researcher and the participants [26,27,29,31]. Of the included studies, Brighton et al. [30], Levack et al. [32], and Glasser et al. [28] were found to have the highest quality. Details of the quality appraisal in Table 2.

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Table 2. Quality appraisal.

https://doi.org/10.1371/journal.pone.0318709.t002

Findings

Four overarching themes and 14 sub-themes were developed in this qualitative evidence synthesis: 1) positive and negative experiences affecting a person’s motivation for their care, 2) patient attitude and beliefs, 3) being able to access and attend care, and 4) the influence of communication and culture on a person’s care. These themes and sub-themes appear key in establishing a deeper understanding of barriers and facilitators of adherence to treatment interventions amongst people living with COPD from minority ethnic communities (Fig 2). A detailed breakdown of each theme can be viewed in the supporting information (S4 Table).

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Fig 2. Developed themes and sub-themes for barriers and facilitators of adherence to treatment interventions of COPD amongst individuals from minority ethnic communities.

https://doi.org/10.1371/journal.pone.0318709.g002

Theme 1: Positive and negative experiences affecting a person’s motivation for their care

Subtheme 1: The influence of healthcare professionals. Healthcare providers were seen to play a vital role in supporting and motivating individuals from minority ethnic communities living with COPD across five articles [26–28,31,32]. Healthcare providers could positively and/or negatively influence a person to attend pulmonary rehabilitation programmes or quit smoking [27,30,32]. Further, a female participant of Hispanic ethnicity recounted a positive experience with her nurse in acquiring and adhering to COPD medication [28].

“Was there anything about the class that made you nervous before you started, or when you first started going? The exercise. I used to think “oh,” you know. and the physio will say “no, keep going, keep going,” you know, you think “I can’t breathe.” I used to be afraid of the breathing.”(Māori) [32].

“I told the doctor that I don’t have the strength and the will power (to quit smoking) and he said: “I cannot deal with you. If you don’t quit smoking, I will see you with an oxygen tank in one year.” And that made me feel very bad.” (Hispanic) [28].

Many participants of South Asian, Hispanic, and African American ethnicities reported that they had never been referred to pulmonary rehabilitation or given the opportunity to discuss attending the programme [27,31]. The lack of continuity in healthcare provider-patient relationships and insufficient consultation time caused people living with COPD to miss out on pulmonary rehabilitation, a valuable opportunity to improve their symptoms, and resulted in delays in accessing crucial interventions.

“No, I have never been referred. They just ask me to continue doing some exercises. I get a lot of exercises since I do all the housework. But I have never been told what you are saying.” (British Pakistani)[31].

“Like I said, my doctor never told me anything about that [PR]. I mean, he could tell his patients when they have severe–chronic breathing, respiratory infections, and things like that. He should advise his patients to just give it a try. If he would have told me to go, I would have went.” (Hispanic) [27].

On the other hand, some participants reported positive experiences with healthcare providers that enabled them to engage in pulmonary rehabilitation and adherence to medication [28,31].

“What I liked and enjoyed most was that it gave me a routine and took me out of the house, I felt good mingling with other people, I enjoyed interacting with them, it helped me relax.” (British Pakistani) [31].

“I don’t have problems (with medications) because I have nurses who come to my house. They come every week on Tuesdays and Fridays. They are lovely, lovely, responsible people.” (Hispanic) [28].

Subtheme 2: Social support from family, friends, and peers. Social networks can also play a role in motivating uptake and adherence to pulmonary rehabilitation and smoking cessation amongst individuals from minority ethnic communities diagnosed with COPD [26,28–30,32]. Participants from Chinese ethnicity in the study by Poureslami et al. conducted in Canada cited the detrimental effect of family and friends as justification for their decision to start smoking or their struggle to quit [26]. People of Māori ethnicity indicated the importance of a culturally familiar environment and being with peers who had similar cultural perspectives in their tendency to attend pulmonary rehabilitation programmes [32].

“I quit once, then I started to smoke again because smoking helps me build close relationships with my friends when we play cards” (Chinese in Canada)[26].

“After coming to Canada, I was forced to quit smoking by my family, my daughters told me to quit and yelled at me.” (Chinese in Canada)[26].

“How it was for me?–I felt very left out, I felt like–being a Māori, you know. They were all in their own individual group, you know, the Pākehā [non-Māori New Zealanders]… I stuck out like a sore thumb, being the only Māori there.” (Māori) [32].

Subtheme 3: The impact of underlying health conditions. Participants of Māori ethnicity in the study by Levack et al. reported the severity of COPD as a barrier to attending and completing the pulmonary rehabilitation programme due to severe symptoms limiting their mobility [32]. Additionally, Poureslami et al. and Glasser et al. found that worsening symptoms of COPD motivated people from minority ethnic communities to quit smoking, as it helped them better manage the disease and improve their quality of life [26,28].

“And that exercise in the hospital gym was rubbish. We had to be there at nine o’clock in the morning, I mean anyone with COPD or severe emphysema know, that’s not a really for us. It takes me over an hour just to have a shower.” (Māori) [32]

“I cut down smoking because I hospitalised for my lung problem, then I cut my one-pack a day smoking [sic] to three packs a month.” (Chinese in Canada)[26].

“I know bad health well. I was in intensive care and I believed that I was going to die. When you see this you quit cigarettes. You say, “Oh my God, if you continue this way you are going to die.” (Hispanic) [28].

Despite that, the beneficial impact of smoking cessation and pulmonary rehabilitation on the health of individuals living with COPD has been identified as a facilitating factor for adherence amongst people of Māori ethnicity, and Chinese people who are resident in Canada [26,32].

“[To start with] I just thought “oh, what we’re going–going to get out of it?” But I thought I’ll keep going. But then I said to them, when I’d been to it for a few times, I used to say, “oh, I must admit, it has been doing me good.” I said–before I used to think oh exercise was just a load of–it’s not going to help you, you know, with all the breathlessness and all that. It’s not going to help you.” (Māori) [32].

“When you quit smoking, your lung function improves, my doctor said.” (Chinese in Canada) [26].

Subtheme 4: Restrictions and regulations in the place they live. Governmental regulation on smoking, including taxes and the prohibition of smoking in public areas, helped individuals of Chinese ethnicity diagnosed with COPD decide to quit smoking after immigrating to Canada [26].

“I quit smoking after coming to Canada and observed that it’s not culturally good habit to smoke.” (Chinese in Canada) [26].

“Smoking is expensive.” (Chinese in Canada) [26].

Theme 2: Patients’ attitudes and beliefs

Subtheme 1: Looking to improve their own health. People’s perspectives about the benefits and health improvements resulting from participating in pulmonary rehabilitation programmes were demonstrated as a facilitator for adherence by some participants from minority ethnic communities; namely, Asian, African American, and Hispanic ethnicities [29,30].

“I’ll go and try anything, I’ve done that a lot, I thought I’ll get there somehow but do something positive. As long as I’m doing something positive to help myself, if you like, I’ll do it.” (Asian, Black, or Mixed) [30].

“I liked them a lot, I wanted to see if this worked for me. It wasn’t easy at first because I wasn’t used to it, but now I can even do them on my own.” (Hispanic or African American) [29].

Subtheme 2: Personal beliefs and drive. Numerous participants with Māori ethnicity pointed out the impact of their beliefs and expectations on their decision-making regarding their participation in and continuation of pulmonary rehabilitation programmes [32]. Levack et al. stated that negative personal perceptions were attributed to attitudes that drives expectations and thoughts about the programmes [32].

“I used to have a bad attitude. I used to think, oh, exercise ain’t going to help me, you know… At first I really had a bit of a negative attitude to it. Cause I have negative attitude to everything. and I’m like “nah, I don’t want to go to that.” You know, I lose interest in things quick. real quick.” (Māori) [32].

Subtheme 3: Trusting healthcare provider. South Asian participants in the study by Early et al. exhibit a strong inclination towards engaging and completing pulmonary rehabilitation programmes by placing significant value on advice provided by healthcare professionals [31]. The authors described trusting and following healthcare recommendations as an enabler to pulmonary rehabilitation uptake [31].

“No they did not tell me anything at all [about what happens at PR]. They said it’s a very good thing, do go. They said will you go if we refer? I said yes.” (British Pakistani) [31]

“Yes I will be interested. I will definitely go if they ask me to.” (British Pakistani) [31]

Subtheme 4: Patient perception of smoking and pulmonary rehabilitation programme. People of Chinese ethnicity who smoke and live with COPD in Canada discussed various reasons to continue smoking in the study by Poureslami et al [26]. Many participants hold the misconception that smoking can alleviate stress and anxiety and fight viruses [26]. They also thought that smoking benefits outweighed its risks and it is considered an effective way for re-energisation and alertness [26]. Additionally, a lack of belief in the advantages of pulmonary rehabilitation was reported as a barrier to attending the programme amongst participants of British Pakistani ethnicity [31].

“Smoking helps with disinfection” (Chinese in Canada) [26].

‘‘I felt more relaxed when I smoked” (Chinese in Canada) [26].

“Honestly, I don’t think there’s anything bad with smoking–but my doctor told me to stop” (Chinese in Canada) [26].

“The exercises were not directly related to my lungs, they showed me exercises which was generally good for my body, there were all kinds of exercises and they taught me bits of all types of exercises. I would say they were excellent; the exercises are somewhat helpful. I have been asked to do them at home, I try to do them regularly but I am unable to do all the exercises the way they showed us in the classes.” (British Pakistani) [31].

Theme 3: Being able to access and attend care

Subtheme 1: Flexibility of attending the services. The flexibility of the programmes impacted the adherence and engagement to the services amongst people from minority ethnic communities. People of Māori, and Asian, ethnicities living with COPD may find their motivation eroded by the timing and duration of pulmonary rehabilitation programmes because of many conflicting obligations, such as those to religion, family and work [30,32].

“I did Wednesday and Friday. But then I couldn’t cope with Friday.”. “I did go, and I said, ‘I can’t do Fridays.” (Asian, Black, or Mixed)[30].

“I found that early morning was not good for me. I couldn’t concentrate on what they were doing. and the last thing I wanted to do was walk.” (Māori) [32].

Subtheme 2: Transport and travel to pulmonary rehabilitation programme. Participants from Māori and South Asian ethnic communities highlighted transportation issues related to attending pulmonary rehabilitation programmes, including cost, distance, and reliance on family [31,32]. Lacked personal transport due to financial constraints and limited access to public transport influencing uptake of pulmonary rehabilitation by people of Māori ethnicity [32]. Similarly, individuals from South Asian ethnic communities identified that limited capital resources and dependence on relatives for transportation as barriers to accessing these services [31].

“I said to her “am I the only Māori coming?” And she said “well there’s meant to be others, but they’re not coming.” And I said “probably because you have to find your own way.” (Māori) [32].

“That I can only be sure after I go, but I will try to complete the course. I was unsure who will take me there. But my daughter said she will. In my locality its once a week only.” (British Pakistani) [31].

Subtheme 3: Opportunities for using digital technology or tele-services for care continuity. Pekmezaris et al. and Polo et al. investigated the acceptability and usability of telehealth pulmonary rehabilitation among people diagnosed with COPD from Hispanic and African American ethnic communities [27,29]. Being able to access pulmonary rehabilitation services from home using tablets facilitated adherence and enabled people of minority ethnic communities to overcome certain attendance-related obstacles such as language [29]. Tablets were modified to use icons, making it easier for patients to access various aspects of the app through point-and-click interaction, regardless of their primary language [29]. However, some participants expressed their feelings of being abandoned because they perceived that the programme had been abruptly withdrawn from their access at the end of the study [27].

“You don’t have to struggle… with all the equipment, everything is set up just right for the patient to access everything.” (Hispanic or African American) [29].

“They give the equipment in order to help you, and then they take it back from you. That breaks the morale of the whole program, you know. It’s like building you up and breaking you down” (African American) [27].

Theme 4: The influence of communication and culture on a person’s care

Subtheme 1: Language and interpretation to enable conversation and understanding. Language barrier was found to have a negative impact on how individuals from minority ethnic communities receive and understand information about pulmonary rehabilitation programmes. This was particularly noted among people from South Asian ethnic communities who mostly required interpreters during appointments due to their limited language proficiency [31]. Reliance on interpreters presented challenges for healthcare providers to accurately interpret emotional cues and fully understand the conversation [31]. Consequently, ineffective coordination of interpretation services resulted in patients feeling marginalised or misunderstood, leading to influence their uptake and adherence to pulmonary rehabilitation.

“Even I did not know much about it till you explained. It is also possible that they did explain but I did not get it properly. They were in English.” (British Pakistani) [31]

“I could not understand [the education part] them. But I had my daughter with me she would explain things to me. I could not understand English.” (British Pakistani) [31].

“We are not very fluent in English. It is possible that this is why people do not go. I don’t understand 100%, but even I were to understand only 50% it is still beneficial. There is no harm.” (British Pakistani) [31].

Subtheme 2: Feelings of belonging within a community. People of Māori ethnicity living with COPD placed considerable value on Whakawhanaungatanga, which is the Māori approach of building and maintaining relationships [32]. Individuals from Māori ethnic community emphasised the importance of connecting with peers who shared similar cultural perspectives, as this influenced their decision to uptake pulmonary rehabilitation [32].

“And it just that whanaungatanga [connecting with others] time is very important, how everyone feels. It’s something personal to yourself. But some get to say more than others… But it’s a kind of down to our level, and it’s good to bringing the tikanga aspect side of things, tikanga Māori, our waiata, how we do things, who with, and in a place that we feel good in being.” (Māori) [32].

Subtheme 3: Appreciating and representing cultures. Individuals from minority ethnic communities have demonstrated an intense appreciation for their cultural heritage, which may have an impact on their engagement in pulmonary rehabilitation programmes. For instance, People from South Asian communities living with COPD cited the presence of mixed-sex classes as a barrier to attending pulmonary rehabilitation programmes [31].

“I did not like this [mixed classes]. Men should be separate from women. This was the most difficult part.” (British Pakistani) [31].

Strengths and limitations

To the best of our knowledge, this meta-ethnographic systematic review is the first to explore the barriers and facilitators affecting adherence to COPD treatment interventions among individuals from minority ethnic communities. Secondly, eMERGe guidelines were followed in reporting the findings of this review. Furthermore, authors (SA, AR-B, HN, AH, and MC) were independently screened studies using pre-designed inclusion criteria. SA and AR-B independently appraised the quality of the studies, and participated in the phases of translation, synthesising translation, and expressing the synthesis, and came to a consensus through discussion.

This review was restricted to studies published in English only; as such, the authors recognise this may have resulted in excluding findings from potentially relevant publications written in other languages. Despite the broad inclusion criteria used in this review, a limited number of qualitative studies were retrieved that reported qualitative data in accordance to participant ethnicity (i.e. matching quotes to participant demographics). As such, the authors make suggestion for more transparent qualitative data reporting. Included studies were only exploring patients’ experience with pulmonary rehabilitation and smoking cessation. Lastly, all minority ethnic communities were treated as a single entity, with any differences and complexities between various ethnic communities being ignored. To further understand the variation of experiences within each minority ethnic community, it would be valuable to identify barriers and facilitators of adherence to treatment interventions of COPD in each minority ethnic community in future studies.

Points for clinical practice, and questions for future research

The implications of the findings of this review have significant relevance for both clinical practice and future research. In practice, understanding the barriers and facilitators experienced by people who are from minority ethnic communities with treatment interventions of COPD allows healthcare providers to tailor interventions and support mechanisms to better address the variety of needs of these communities. By recognising and addressing cultural, social, and linguistic factors that impact decisions about COPD treatment, healthcare providers could enhance patient adherence and eventually improve treatment outcomes. Moreover, this review highlights the importance of developing rapport and trust between healthcare professionals and individuals living with COPD who are from minority ethnic communities, emphasising the need for ethnic-sensitive care delivery. For future research, these findings indicated the necessity of further exploration into the unique challenges faced by people from minority ethnic communities in managing COPD. It is crucial to develop patient-centred interventions that address any disparities while considering the influence of language and culture. Previous qualitative studies have often excluded non-English speakers, leaving a significant gap in understanding how these factors impact the management of COPD amongst people of minority ethnic communities. Therefore, qualitative research that involves non-English speakers of minority ethnic communities is essential for a comprehensive understanding of the influence of ethnicity on adherence to treatment interventions for COPD.