Chronic obstructive pulmonary disease (COPD) significantly burdens Brazil, ranking as the fifth leading cause of death and eighth most significant cause of years of life lost. Chronic tobacco exposure is the primary cause, but environmental pollutants also play a role. COPD is a major cause of hospitalization within the Brazilian Unified Health System (SUS), incurring substantial annual costs. The disease's progressive airflow limitation leads to dyspnea, chronic cough, reduced exercise capacity, muscle weakness, and diminished quality of life (QoL). Exacerbations, responsible for over 70% of healthcare costs, significantly worsen symptoms and QoL. COPD patients often have multiple comorbidities (average 3-4), including osteoporosis, cancer, diabetes, metabolic syndrome, depression, anxiety, and fatigue. The presence of comorbidities is linked to poorer outcomes. Anxiety and depression are highly prevalent among COPD patients, exceeding rates in the general population or those with other chronic illnesses, negatively affecting well-being and physical functioning and are often neglected or undertreated. While smoking cessation improves COPD and mental health, physical activity (PA) also offers substantial benefits, reducing hospitalization and mortality risks. However, physical inactivity (PI) is common among COPD patients, further complicated by anxiety and depression. Pulmonary rehabilitation (PR) is a standard non-pharmacological recommendation, encompassing physical training, education, and behavior change. Successful PR improves symptoms, QoL, lung function, and exercise capacity. However, access to PR is severely limited in Brazil and other low- and middle-income countries (LMICs) due to factors such as lack of awareness, referral challenges, and limited access, particularly to hospitals. Community-based PA programs provide an important, sometimes sole, alternative for those unable to access PR or needing maintenance after PR. This study aimed to explore the experiences of living with COPD and participation in PA among COPD patients in an urban Brazilian setting, including those with anxiety and depression, who are least likely to participate but stand to gain the most.

Existing literature highlights the significant impact of COPD on physical and mental well-being, emphasizing the importance of physical activity in mitigating these effects. Studies in high-income countries have explored the perceptions of PA among people with COPD; however, research specifically focusing on the Brazilian context, particularly concerning individuals with co-occurring mental health conditions, remains limited. The literature supports the efficacy of pulmonary rehabilitation (PR) in improving COPD outcomes, but acknowledges its inaccessibility in many low- and middle-income countries due to financial and logistical barriers. This gap in research underscores the necessity for understanding the lived experiences of COPD patients in resource-constrained settings and exploring the feasibility and effectiveness of community-based PA interventions tailored to this population. The literature also reveals the complex interplay between COPD, anxiety, depression, and physical activity participation, emphasizing the importance of addressing these co-occurring conditions comprehensively.

This qualitative study employed semi-structured telephone interviews conducted between October 2020 and April 2021. Ethical approvals were obtained from relevant ethics committees. Participants included individuals with established and newly diagnosed COPD, recruited from primary care centers (Basic Health Units or BHUs) and specialized polyclinics in São Bernardo do Campo, São Paulo, Brazil. Purposive sampling was used, selecting participants based on factors such as history of anxiety/depression, symptom severity, COPD diagnosis status, age, gender, activity levels, and education level. A screening questionnaire was administered to eligible patients, followed by informed consent procedures. Telephone interviews, conducted by the principal investigator (a primary health care physician and PhD student), explored patients' knowledge of COPD, anxiety, depression, PA, and opinions on community-based PA. Baseline data included sociodemographic information, smoking status, medical records, spirometry results (FEV1), breathlessness measures (mMRC scale), COPD impact assessment (CAT), depression assessment (PHQ-9), anxiety assessment (GAD-7), PA assessment (Godin Leisure-Time Exercise Questionnaire), and psychological distress assessment (GHQ-12). Interviews were audio-recorded, transcribed verbatim, and analyzed using the Framework method. The Framework method facilitated a systematic approach suitable for large datasets and multidisciplinary teams. Data were managed using NVivo 11, with multiple readings of transcripts and iterative development of a coding framework. Thematic saturation was reached after 21 interviews.

Twenty-one participants were interviewed, with an average age of 67 (range 52–85), 11 females, and varying COPD severity. Only 23.8% regularly engaged in PA, and 76.2% experienced severe psychological distress. Five key themes emerged: 1. **Knowledge about COPD and its management:** Participants demonstrated limited knowledge of COPD's causes, symptoms, and management, often attributing symptoms to age or lifestyle factors rather than seeking appropriate care. Many were surprised to receive an advanced-stage diagnosis. Smoking was widely acknowledged as a significant contributing factor. Concerns were raised regarding physicians' lack of knowledge in identifying COPD, leading to misdiagnosis as bronchitis or asthma. Access to treatment and medication was highlighted as both beneficial and challenging, with delays in specialist consultations and medication delivery being common. Ongoing smoking hindered treatment efficacy. 2. **Self-perception of life with COPD:** Participants viewed COPD as incurable, but expressed hope in treatment. The disease profoundly impacted their QoL, limiting daily activities and work, affecting their sex life, and reducing social interactions. Feelings of loss of freedom and independence were common, accompanied by increased psychological burden. 3. **Opinions on PA practice:** Most recognized the benefits of PA for well-being and symptom improvement. However, barriers such as dyspnea, time constraints, accessibility, weather conditions, physical comorbidities, depression, and obesity were identified. While some used community spaces for PA (squares, BHUs, associations), engagement was limited, with walking, dancing, and weight training being common. A community-based COPD-specific PA program was highly desired. 4. **Knowledge and experiences about depression and anxiety:** Depression and anxiety were seen as exacerbating COPD symptoms. Limited knowledge about depression existed, with disappointment, financial problems, and losses cited as potential causes. Reported symptoms included sadness, anguish, anhedonia, lack of initiative, irritability, and social isolation. Depression significantly impacted PA participation. 5. **Repercussions of the COVID-19 pandemic:** The pandemic negatively impacted access to health services, PR, and PA, leading to increased social isolation, psychological distress, anxiety, and depressive symptoms. Fear of confusing COPD symptoms with COVID-19 and the challenges of mask use were also raised.

This study reveals a critical need to improve COPD awareness among patients, the public, and healthcare professionals, emphasizing the importance of early diagnosis and management. The findings highlight the inadequacy of primary health care in recognizing early COPD symptoms and the need for collaborative care models to improve patient outcomes. The study confirms the significant impact of COPD on physical and psychological well-being, underscoring the multifaceted challenges faced by individuals with the disease. The results reveal a strong interest in community-based PA programs, yet acknowledge the significant barriers to regular participation. Addressing depression and anxiety is crucial for improving PA adherence and overall well-being. The COVID-19 pandemic further exacerbated challenges related to access to care and PA. The data inform the development of targeted interventions that address the specific needs and contextual factors within the urban Brazilian setting.

This qualitative study underscores the urgent need for improved COPD knowledge and management in Brazil. Findings highlight the critical role of community-based PA programs in improving both physical and mental health outcomes. The study provides crucial information to guide public policy development and intersectoral partnerships in designing and implementing effective, accessible, and culturally relevant interventions for people with COPD.

This study's limitations include the relatively small sample size and the use of telephone interviews conducted during the COVID-19 pandemic, which may have influenced participants' experiences and responses. The purposive sampling strategy, while appropriate for qualitative research, limits the generalizability of the findings to other populations. The reliance on self-reported data introduces the potential for recall bias and social desirability bias.