Associations of chronic obstructive pulmonary disease with life satisfaction and self-rated health: quantifying the subjective burden in a population-based study

Subjective wellbeing has become an increasingly important focus in public health, reflecting recognition that health encompasses physical, psychological, and social dimensions [1‐3]. It is now widely accepted that health cannot be fully understood through clinical indicators alone [4‐6]. Instead, how individuals perceive and evaluate their own health and quality of life is essential for informing policy and service delivery [7]. In line with recommendations from international organisations such as the World Health Organization [8] and the Organisation for Economic Co-operation and Development [9], population surveys increasingly include brief self-report measures of subjective wellbeing and perceived health status—most commonly life satisfaction as an indicator of overall wellbeing and self-rated health as a global assessment of personal health. Both measures are routinely included in population health surveys and have demonstrated utility for predicting mortality, healthcare utilisation, and future health decline [8].

Despite their widespread adoption, questions remain about the validity of these single-item measures in accurately capturing the lived experience of chronic illness. While self-rated health and life satisfaction are often assumed to reflect underlying wellbeing and health status [9‐13], this assumption has rarely been tested directly using well-defined chronic disease groups. Chronic obstructive pulmonary disease (COPD) offers an appropriate context to examine this issue. COPD is a progressive respiratory condition that leads to persistent symptoms such as breathlessness, cough, and fatigue and often results in functional impairment, psychological distress, social isolation, and diminished quality of life [14]. Given these impacts, individuals with COPD would be expected to report substantially lower levels of subjective wellbeing and health status. Empirical confirmation of this pattern would strengthen confidence in the use of self-rated health and life satisfaction as indicators of health burden in population-level surveillance and research.

Although numerous studies have documented the negative impact of COPD on physical functioning and health-related quality of life, most have relied on disease-specific instruments such as the St George’s Respiratory Questionnaire or the COPD Assessment Test [14]. Far fewer have examined whether general population indicators, such as self-rated health and life satisfaction, accurately mirror this burden. Establishing such correspondence is important for validating the use of brief wellbeing and health indicators in national surveys, particularly when condition-specific assessments are unavailable. Evaluating the sensitivity of subjective wellbeing measures to a condition such as COPD is particularly relevant for informing health inequality monitoring. COPD disproportionately affects older adults, people from socioeconomically disadvantaged backgrounds, and those with a history of smoking. If subjective wellbeing and health indicators consistently reflect poorer outcomes in these populations, they can serve as valuable tools for assessing the distribution of health burden and targeting interventions [8, 9]. Moreover, since these indicators are brief and cost-effective to collect, they offer practical advantages for repeated measurement in national surveys.

This study used data from four recent waves of the Scottish Health Survey to examine whether two commonly used subjective measures, self-rated health and life satisfaction, are associated with the presence of COPD, thereby assessing their construct validity as indicators of subjective health burden. We assessed whether individuals with COPD report significantly poorer outcomes on these indicators, even after accounting for sociodemographic characteristics, smoking status, and mental health. We also examined whether these associations differ across levels of area deprivation.

The primary exposure variable in this study was COPD, ascertained through self-report. Respondents were asked whether they had ever been told by a doctor that they had COPD. This approach reflects clinical diagnosis as understood and recalled by the participant. Responses were coded as “COPD” or “No COPD.” Participants who responded “don’t know” were excluded from the analysis due to lack of diagnostic certainty.

Two outcomes were analysed as indicators of subjective wellbeing and health: life satisfaction and self-rated health.

Life satisfaction was assessed using a single-item question: “All things considered, how satisfied are you with your life as a whole nowadays?” Respondents rated their satisfaction on a scale from 0 to 10, where 0 indicated “extremely dissatisfied” and 10 indicated “extremely satisfied.” For the main analysis, scores were categorised into three ordered groups based on their position relative to the mode of the distribution: low satisfaction (scores 0–7), moderate satisfaction (score of 8, which was the modal value), and high satisfaction (scores 9–10). This categorisation is consistent with the approach used in the Scottish Health Survey annual reports, which apply the same grouping to reflect the skewed distribution of responses and the strong clustering at a score of 8.

Self-rated (subjective) health was measured using the question, “How is your health in general?” with five response options: very good, good, fair, bad, and very bad. These responses were grouped into three ordinal categories: very good/good (coded as 1), fair (coded as 2), and bad/very bad (coded as 3), with higher values indicating poorer health.

Covariates were selected a priori based on theoretical relevance and empirical evidence linking them to both COPD and subjective health and wellbeing [18, 19]. These covariates accounted for key sociodemographic, behavioural, and health-related factors that could confound the association between COPD and the two outcome measures. Age was categorised into four groups: 16–34, 35–54, 55–64, and 65 years and older. Sex was coded as male or female. Smoking status was classified into four categories based on self-reported smoking history: never smoker, ex-smoker (occasional), ex-smoker (regular), and current smoker. Ethnicity was dichotomised as White or Non-White due to small numbers in minority ethnic groups. Educational attainment was grouped into three categories: higher education (e.g. university degree or equivalent), secondary or college level qualification, and lower or no qualification. Area-level deprivation was measured using the Scottish Index of Multiple Deprivation 2020 (SIMD). Urban or rural residence was included based on the respondent’s postcode classification, categorised as urban or rural. Finally, the presence of a self-reported mental health condition was included as a binary variable (yes or no), based on whether respondents reported being diagnosed with depression, anxiety, or another mental health condition.

Table 1 presents the sociodemographic and health-related characteristics of the study population (n = 18,563), stratified by COPD status. Among the 855 individuals with COPD, a markedly older age profile was observed compared to those without the condition: 61.5% were aged 65 and above, compared to 30.0% in the non-COPD group (p < 0.001). Sex distribution was similar between groups (p = 0.535), with women comprising 57.2% of the COPD group and 56.1% of those without COPD. Marked differences emerged in smoking status (p < 0.001). Nearly half of individuals with COPD were regular ex-smokers (46.1%), and over a third were current smokers (35.9%), compared to 24.2% and 13.2%, respectively, in those without COPD. Individuals with COPD were also significantly less likely to have never smoked (16.3% vs. 55.7%). Educational attainment and area deprivation differed significantly by COPD status (both p < 0.001). More than half (52.1%) of those with COPD had lower or no educational qualifications, compared to 17.1% among those without COPD. Similarly, 32.2% of individuals with COPD lived in the most deprived SIMD quintile, while only 11.1% were in the least deprived category. Mental health conditions were more prevalent among those with COPD (18.6%) compared to those without (10.6%; p < 0.001). Urban residence was slightly more common in the COPD group (84.0%) than in the non-COPD group (77.9%; p < 0.001).

Table 2 presents the crude and adjusted odds ratios for the associations between COPD and the two subjective indicators, life satisfaction and self-rated health, among adults in Scotland. In the unadjusted model, individuals with COPD had 60% lower odds of reporting higher life satisfaction compared with those without COPD (crude OR = 0.40; 95% CI 0.35–0.46; p < 0.001). After adjustment for age, sex, smoking status, ethnicity, education, area-level deprivation, urban/rural residence, and mental health condition, the association remained strong and statistically significant (adjusted OR = 0.51; 95% CI 0.44–0.59; p < 0.001). For self-rated health, individuals with COPD had substantially higher odds of reporting poorer health in the crude analysis (OR = 8.70; 95% CI 7.64–9.92; p < 0.001). After controlling for the same covariates, the association remained robust (adjusted OR = 4.24; 95% CI 3.68–4.89; p < 0.001). The results presented are from models without survey-year adjustment; however, a sensitivity analysis that included survey year (2018–2022) yielded similar estimates, with no material change in the direction or magnitude of the associations.

Figure 1 shows the predicted probability of reporting low life satisfaction (score 0–7) across area-level deprivation quintiles, stratified by COPD status. In all deprivation groups, individuals with COPD had a significantly higher probability of low life satisfaction compared to those without COPD (all p < 0.001). Among the least deprived, the probability of low life satisfaction was 43.2% (95% CI 34.5–51.9) for individuals with COPD, compared to 30.4% (95% CI 29.1–31.7) for those without—an absolute difference of 12.8% points. The disparity peaked in the 4th deprivation quintile, where 49.4% (95% CI 41.4–57.4) of individuals with COPD reported low satisfaction versus 30.1% (95% CI 28.9–31.3) of those without, yielding a 19.3% point difference. While the probability of low life satisfaction increased with deprivation in both groups, the gap between COPD and non-COPD respondents remained broadly similar, ranging from 10.2 to 19.3% points. A likelihood ratio test comparing models with and without the interaction term (COPD × SIMD) indicated no significant effect modification by deprivation (LR χ²(4) = 5.58, p = 0.23).

Figure 2 presents the predicted probability of reporting very good or good self-rated health across deprivation quintiles, stratified by COPD status. Across all deprivation levels, individuals with COPD were substantially less likely to report favourable health than those without the condition (all p < 0.001). In the least deprived group, 78.7% (95% CI 77.3–80.0) of non-COPD respondents reported good or very good health, compared to 54.1% (95% CI 45.7–62.5) of those with COPD—a 24.6% point gap. The disparity widened further in middle quintiles, peaking in the 3rd quintile with a 34.7% point gap (72.2% vs. 37.5%). Among the most deprived, 62.4% (95% CI 60.6–64.1) of non-COPD individuals reported very good or good health, while only 34.3% (95% CI 29.3–39.2) of individuals with COPD did so—a 28.1% point difference. To formally assess whether the relationship between COPD and self-rated health differed by deprivation level, an interaction term (COPD × SIMD) was included in the model. The interaction was not statistically significant (LR χ²(4) = 4.62, p = 0.33).

This study provides evidence that individuals living with COPD report significantly poorer subjective wellbeing and health status, as measured by both self-rated health and life satisfaction. These findings are consistent with the clinical understanding of COPD as a debilitating chronic condition marked by persistent breathlessness, fatigue, and limitations in daily functioning [21]. Importantly, even after adjusting for smoking status, sociodemographic factors, and mental health conditions, individuals with COPD had more than four times the odds of reporting poor self-rated health and roughly half the odds of reporting higher life satisfaction. Although the primary aim of this study was to examine these associations rather than to validate the measures themselves, the strength and consistency of the findings suggest that these brief, single-item indicators can meaningfully reflect the lived burden of chronic disease. Prior studies have shown that poor self-rated health predicts hospitalisation, functional decline, and mortality [22‐25]; our results extend this evidence by demonstrating that these wellbeing measures can clearly distinguish between individuals with and without a chronic respiratory condition such as COPD. The consistent patterns across both wellbeing outcomes further strengthen confidence in their utility as concise, population-relevant public health indicators.

Furthermore, individuals with COPD had lower levels of wellbeing across all levels of deprivation, and predicted probabilities of poor outcomes were markedly higher in the most deprived groups. These patterns reflect the well-documented concentration of COPD in socioeconomically disadvantaged populations, driven by higher rates of smoking, occupational exposures, and limited access to timely diagnosis and care [26]. The consistently poorer wellbeing observed among individuals with COPD across the deprivation gradient suggests that COPD exerts a substantial, independent effect on subjective experience, regardless of material context. Although deprivation itself was strongly associated with reduced wellbeing, the lack of a significant interaction between COPD and deprivation indicates that the detrimental effects of COPD on wellbeing were broadly similar across socioeconomic strata. However, COPD remains disproportionately concentrated in deprived communities, meaning that population-level burdens are amplified by social disadvantage [27‐29].

While the use of single-item measures such as self-rated health and life satisfaction offers clear advantages in terms of simplicity, comparability, and feasibility for large-scale population surveys, they inevitably capture only a subset of the broader dimensions of wellbeing. Multi-item instruments such as the EQ-5D and WHOQOL provide richer assessments of specific domains including physical function, social participation, and psychological wellbeing [30‐32]. However, our findings indicate that even brief, single-item questions are sufficiently sensitive to distinguish between individuals with and without COPD, suggesting that they remain valuable tools for public health monitoring where brevity and respondent burden are key considerations [33]. Future research may build on these findings by comparing the performance of single- and multi-item measures within the same populations to assess their relative validity and responsiveness.

These findings have clear implications for the use of self-rated health and life satisfaction as monitoring tools in public health research. First, they offer empirical support for the construct validity of these single-item measures as indicators of disease burden, especially in chronic conditions like COPD where functional impairment and emotional distress are prominent. Researchers and policymakers can be more confident in using these indicators to track health trends, allocate resources, and evaluate the population-level impact of chronic diseases. Second, the study illustrates the utility of generalised ordered logit models for testing the proportional odds assumption in ordinal outcomes, a methodological approach that may be underused in health inequalities research. Finally, the robustness of associations after adjusting for confounders suggests that these measures may serve as equity-sensitive metrics, capable of capturing disparities in health experience that might be missed by clinical or administrative records. Future research could explore their performance in other disease groups, their responsiveness to intervention, and their predictive value for long-term outcomes.

A major strength of this study is the use of nationally representative data from four recent waves of the Scottish Health Survey, providing sufficient statistical power and generalisability to the adult population of Scotland. The inclusion of both self-rated health and life satisfaction offers a broader assessment of subjective wellbeing than studies relying on a single indicator. The use of generalised ordered logit models represents a methodological advance by accommodating partial violations of the proportional odds assumption, thereby yielding more accurate estimates.

However, several limitations should be acknowledged. The identification of COPD was based on self-report of a prior clinical diagnosis, which may be prone to recall error or underreporting, particularly among individuals with limited access to healthcare. Such misclassification is likely to be non-differential and would therefore bias the observed associations toward the null, implying that the true relationship between COPD and subjective wellbeing may be even stronger than reported. Given the cross-sectional design, causality cannot be inferred [34], and the temporal sequence between COPD and wellbeing remains unclear. It is also possible that poorer wellbeing could influence the reporting or perception of respiratory symptoms or increase healthcare-seeking behaviour, leading to higher likelihood of COPD diagnosis—introducing potential reverse causation. Moreover, the survey was not designed specifically for this analysis, limiting access to clinical indicators such as disease severity or lung function measures. While the models adjusted for key sociodemographic, behavioural, and mental health covariates, residual confounding by unmeasured factors cannot be ruled out. Despite these limitations, the consistency and magnitude of associations observed across wellbeing measures provide strong evidence that COPD is associated with substantially poorer perceived health and life satisfaction in the Scottish adult population.

This study provides clear evidence that individuals living with chronic obstructive pulmonary disease experience significantly poorer subjective health and wellbeing, as reflected in both self-rated health and life satisfaction. These associations remained strong even after adjusting for sociodemographic characteristics, smoking history, and mental health status, underlining the substantial impact of COPD on perceived health and quality of life. By demonstrating that brief, single-item wellbeing measures consistently differentiate those with COPD from the general population, our findings support their construct validity as indicators of chronic disease burden in population health surveillance. As public health systems increasingly prioritise person-centred outcomes and seek efficient ways to monitor health inequalities, these measures offer a valuable and scalable tool for capturing the lived experience of illness. Further research is warranted to assess their responsiveness to intervention and applicability across other long-term conditions.