Health belief model predicts adherence to CPAP before experience with CPAP

Personality traits and pre-treatment beliefs and cognitions predicting patient adherence to continuous positive airway pressure: A systematic review

Adherence to Continuous Positive Airway Pressure (CPAP) for obstructive sleep apnoea (OSA) can be improved by behavioural interventions which modify patients' beliefs and cognitions about OSA, CPAP, and themselves. We have conducted the first systematic review of the literature on beliefs and cognitions held before starting treatment, and personality (which influences the former) that predict the decision to purchase or start CPAP, or CPAP adherence one month or more after CPAP initiation. A systematic search and screen of articles identified 21 eligible publications from an initial 1317. Quality assessment performed using an adapted Newcastle-Ottawa Scale demonstrated that 13 (62%) studies were poor quality and only seven (33%) were high quality. Eighteen factors, such as self-efficacy (confidence) in using CPAP and value placed on health predicted CPAP adherence; however, for only six (33%), utility as an intervention target is known, from calculation of individual predictive power. Studies did not use new behavioural frameworks effective at explaining adherence behaviours, nor did they interview patients to collect in-depth data on barriers and facilitators of CPAP use. Future studies cannot have these limitations if high quality evidence is to be generated for intervention development, which is currently sparse as highlighted by this review.

The firstly visited department affects the acceptance of CPAP in patients with obstructive sleep apnea: a cohort study

BACKGROUND

Continuous positive airway pressure (CPAP) therapy is the first-line treatment for obstructive sleep apnea (OSA). However, the low acceptance rate of CPAP remains a challenging clinical issue. This study aimed to determine the factors that influence the acceptance rate of CPAP.

METHODS

This retrospective cohort study was conducted at the sleep center of Shuang-Ho Hospital. Initially, 1186 OSA patients who received CPAP therapy between December 2013 and December 2017 were selected, and finally, 1016 patients were analyzed. All patients with OSA received CPAP therapy for at least 1 week, and their acceptance to treatment was subsequently recorded. Outcome measures included patients' demographic and clinical characteristics (sex, age, BMI, comorbidities, history of smoking, and the medical specialist who prescribed CPAP treatment), polysomnography (PSG) results, and OSA surgical records.

RESULTS

Patients with a lower CPAP acceptance rate were referred from otolaryngologists (acceptance rate of otolaryngology vs. others: 49.6% vs. 56.6%, p = .015), in addition to having a lower apnea-hypopnea index (AHI) (acceptance vs. non-acceptance: 55.83 vs. 40.79, p = .003), rapid eye movement AHI (REM-AHI) (acceptance vs. non-acceptance: 51.21 vs. 44.92, p = .014), and arousal index (acceptance vs. non-acceptance: 36.80 vs. 28.75, p = .011). The multiple logistic regression model showed that patients referred from otolaryngology had a lower CPAP acceptance rate (odds ratio 0.707, p = .0216) even after adjusting for age, sex, BMI, AHI, REM-AHI, arousal index, comorbidities, and smoking status.

CONCLUSIONS

Before their initial consultation, patients may already have their preferred treatment of choice, which is strongly linked to the type of medical specialists they visit, and consequently, affects their rate of acceptance to CPAP therapy. Therefore, physicians should provide personalized care to patients by exploring and abiding by their preferred treatment choices.

Morning Chronotype Is Associated with Improved Adherence to Continuous Positive Airway Pressure among Individuals with Obstructive Sleep Apnea

Rationale: Poor adherence limits the effectiveness of continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA). A better understanding of CPAP adherence is needed to develop novel strategies to improve it. Objectives: To determine if the chronotype (morning, evening, or intermediate) of patients with OSA is associated with differences in CPAP adherence. If such an association exists, determine the mechanisms underlying this association. Methods: We performed a secondary analysis of the APPLES (Apnea Positive Pressure Long-term Efficacy Study) clinical trial. We assessed chronotype using the Morningness-Eveningness Questionnaire (MEQ) among participants randomized to the CPAP arm with daily adherence data (n = 469). Evening (MEQ ⩽ 41), intermediate (41 < MEQ < 59), and morning type (MEQ ⩾ 59) categories were the exposures. We modeled daily CPAP use (hours per night) over a 6-month period, using a linear mixed model, adjusted for covariates (e.g., age, sex, marital status). To assess mechanisms of the association, we performed mediation analyses using sleep duration, weekend catch-up sleep, depression, and other factors. Results: Most participants were obese men with severe OSA (body mass index of 32.3 ± 7.3 kg/m2, 65% male, and apnea-hypopnea index 39.8 ± 24.6/h). Participants were 44% morning, 47% intermediate, and 8% evening chronotype. Participants with the morning chronotype reported the shortest sleep duration on weekends (7.3 vs. 7.6 and 7.9 h/night) compared with the intermediate and evening types. Participants with the morning chronotype exhibited a 40-min/night higher CPAP use (P = 0.001) than persons with the intermediate chronotype. This relationship was mildly attenuated (32.8 min/night; P = 0.011) after adjustment for covariates. None of the selected factors (e.g., sleep duration, weekend catch-up sleep) exhibited a significant mediation effect. Conclusions: Morning chronotype is associated with a clinically meaningful increase in CPAP adherence compared with other chronotypes. Mechanisms of this association require further study. Chronotype may be a novel predictor of CPAP adherence. Clinical trial registered with www.clinicaltrials.gov (NCT00051363).

Investigating associations between social determinants, self-efficacy measurement of sleep apnea and CPAP adherence: the SEMSA study

Study objectives

The prospective Self-Efficacy Measure for Sleep Apnea study (SEMSAS) is investigating thresholds for health literacy, self-efficacy and precariousness at obstructive sleep apnea (OSA) diagnosis to predict CPAP adherence. This paper describes the study protocol and presents baseline data from the ongoing study.

Methods

Eligible individuals had confirmed OSA and were referred to a homecare provider for continuous positive airway pressure (CPAP) therapy initiation. Data on patient characteristics and comorbidities were collected, along with baseline evaluations of self-efficacy [15-item Self-Efficacy Measure for Sleep Apnea tool (SEMSA-15)], precariousness [Deprivation in Primary Care Questionnaire (DipCareQ)], and health literacy (Health Literacy Questionnaire). CPAP adherence over 12 months of follow-up will be determined using remote monitoring of CPAP device data. The primary objective is to define an optimal SEMSA-15 score threshold to predict CPAP adherence at 3- and 12-month follow-up.

Results

Enrollment of 302 participants (71% male, median age 55 years, median body mass index 31.6 kg/m²) is complete. Low self-efficacy (SEMSA-15 score ≤ 2.78) was found in 93/302 participants (31%), and 38 (12.6%) reported precariousness (DipCareQ score > 1); precariousness did not differ significantly between individuals with a SEMSA-15 score ≤ 2.78 versus >2.78. Health literacy was generally good, but was significantly lower in individuals with versus without precariousness, and with low versus high self-efficacy.

Conclusion

SEMSAS is the first study using multidimensional baseline assessment of self-efficacy, health literacy and precariousness, plus other characteristics, to determine future adherence to CPAP, including CPAP adherence trajectories. Collection of follow-up data is underway.

The individual and societal price of non-adherence to continuous positive airway pressure, contributors and strategies for improvement

INTRODUCTION

Continuous positive airway pressure (CPAP) is the first line therapy for obstructive sleep apnea (OSA). CPAP is highly effective for improving symptoms and quality of life but the major issue is adherence, with up to 50% of OSA discontinuing CPAP in the first 3 years after CPAP initiation.

AREAS COVERED

We present the individual and societal cost of non-adherence to CPAP, factors associated with non-adherence to CPAP, as well as current strategies for improving adherence including telehealth, couples-based interventions and behavioral interventions. We also report on challenges and pitfalls for the visualization and analysis of CPAP remote monitoring platforms.

EXPERT OPINION

CPAP termination rates and adherence to therapy remain major issues despite technical improvements in CPAP devices. The individual and societal price of non-adherence to CPAP for OSA patients goes beyond excessive sleepiness and includes cardiovascular events, all-cause mortality, and increased health costs. Strategies for improving CPAP adherence should be individually tailored and aim to also improve lifestyle habits including physical activity and nutrition. Access to these strategies should be supported by refining visualization dashboards of CPAP remote monitoring platforms, and by disseminating telehealth and innovative analytics, including artificial intelligence.

Sleep and self-efficacy: The role of domain specificity in predicting sleep health

OBJECTIVES

Although a number of empirically supported sleep interventions exist, sleep-related beliefs remain largely unexplored as clinical tools for enhancing existing interventions. The present study aimed to determine the differential associations between general and sleep self-efficacy with sleep health among a sample of adults PARTICIPANTS: Participants were 3284 adults (Mean Age = 43 years, 48.5% female, 6.4% other-identifying, 80.8% white).

MEASUREMENTS

Participants completed measures of self-efficacy (general and sleep self-efficacy) and sleep health as part of their involvement in a larger online study. General self-efficacy and sleep self-efficacy were measured with the General Self-Efficacy and Sleep Self-Efficacy scales respectively. Sleep was assessed with the RegUlarity, Satisfaction, Alertness, Timing, Efficiency, Duration scale. A structural equation model was conducted to determine the associations between measures of general and sleep self-efficacy and sleep health, represented by 2-factors derived from the RegUlarity, Satisfaction, Alertness, Timing, Efficiency, Duration measure.

RESULTS

The structural model evidenced adequate to good fit to the data and indicated that both general and sleep self-efficacies were directly associated with the latent sleep quality/quantity and circadian rhythm outcomes. Higher general and sleep self-efficacies were positively associated with sleep regularity, timing, and alertness. Higher sleep self-efficacy and lower general self-efficacy were associated with higher sleep satisfaction, duration, and efficiency.

CONCLUSIONS

Findings highlight the importance of domain specificity in the association between self-efficacy and sleep health outcomes. There is a need for more research into and application of interventions targeted toward increasing sleep self-efficacy as a potential avenue to improve sleep health.

Effects of respiratory training on obstructive sleep apnea: systematic review and meta-analysis

PURPOSE

This systematic review sought to answer the following focused question: "What are the effects of respiratory training devices on obstructive sleep apnea (OSA) outcomes in adults?" METHODS : The acronym "PICOS" was used to determine eligibility criteria, which consists of (P population) = adults with mild to moderate OSA, (I intervention) = spirometry devices or breathing exercises, (C comparison) = compared to no breathing exercises in adults (> 18 years) with mild to moderate OSA, (O outcomes) = improved sleep quality (sleep quality indexes) and improved apnea-hypopnea indexes (AHI), (S study types) = randomized, pseudo-randomized, and non-randomized clinical trials. The search was performed in the following databases: PubMed/Medline, LILACS, Scopus, Web of Science, Scopus, and Cochrane Library, in addition to gray literature through Google Scholar, Proquest, and Open Grey. The risk of bias was assessed using the Cochrane Collaboration tool. The certainty of the evidence was assessed using the GRADE tool. Meta-analyses of random effects were performed for the outcomes of interest.

RESULTS

A total of 1171 references were found. Applying the eligibility criteria, six studies were included in qualitative synthesis. Expiratory exercises showed a decrease in the apnea-hypopnea index (AHI) when compared to baseline (MD =  - 8.4; 95% CI =  - 12.4 to - 4.4; I2 = 19%). There was a decrease in values compared to baseline (MD =  - 4.4; 95% CI =  - 8.2 to - 0.6; I2 = 0%) for the Epworth Sleepiness Scale (ESS), when considering the inspiratory exercises. Both groups of breathing exercises showed a significant decrease in the mean index assessed by the Pittsburgh Sleep Quality Index (PSQI).

CONCLUSION

Results of this meta-analysis suggests that breathing exercises lead to a measurable improvement in AHI for patients with mild to moderate OSA, as well as an improvement in sleep quality and daytime sleepiness.

SYSTEMATIC REVIEW REGISTRATION

CRD42020148513 (PROSPERO).

Racial Differences in Positive Airway Pressure Adherence in the Treatment of Sleep Apnea

Although data are limited, studies suggest on average lower positive airway pressure use in Black, indigenous, and people of color (BIPOC) compared with Whites in most but not all studies. Most of these observational studies are certainly limited by confounding by socioeconomic status and other unmeasured factors that likely contribute to differences. The etiology of these observed disparities is likely multifactorial, due in part to financial limitations, differences in sleep opportunity, poor sleep quality due to environmental disruptions, and so forth. These disparities in sleep health are likely related to chronic inequities, including experiences of racism, neighborhood features, structural, and contextual factors. Dedicated studies focusing on understanding adherence in BIPOC are lacking. Further research is needed to understand determinants of PAP use in BIPOC subjects and identify feasible interventions to improve sleep health and reduce sleep apnea treatment disparities.

Randomized controlled trial on the efficacy of audio-visual health educational materials on CPAP adherence: the AHEAD trial

STUDY OBJECTIVES

Educational interventions have been proposed to improve continuous positive airway pressure (CPAP) adherence; however, studies to date have not demonstrated robust effectiveness, due to methodological issues. Furthermore, these educational interventions have not specifically targeted low health literacy communication techniques, which have been demonstrated to improve outcomes in numerous other chronic diseases. We hypothesized that the addition of low-cost audio-visual educational videos (EVs) to usual standard-of-care (SC) education would improve CPAP adherence in adults with obstructive sleep apnea (OSA) syndrome.

METHODS

At CPAP initiation, treatment-naïve adults with OSA syndrome were randomized to (1) usual SC or (2) SC + 5 EVs showing a patient's journey, designed with low health literacy communication techniques to teach patients about OSA and CPAP therapy. The primary endpoint was CPAP usage at 2 months (hours/night) and secondary endpoints were CPAP usage at 12 months and percentage of patients with ≥ 4 hours/night use at 2 months and 12 months.

RESULTS

One hundred and ninety-five patients were randomized (SC 99, EV 96), with a mean age of 57 years (interquartile range [IQR] 44.1-64.8 years). There were no statistically significant differences in patient characteristics at baseline between the SC vs EV groups, with the diagnostic apnea-hypopnea index of 34 events/h (IQR 21-59 events/h) vs 30 events/h (IQR 20-50 events/h) and Epworth Sleepiness Scale score of 12.8 ± 6 vs 11.7 ± 5. At 2 months, there was no significant difference in hours of CPAP usage (SC: 3.45 hours/night [95% confidence interval (CI): 2.76 to 4.13] vs EV: 3.75 hours/night [95% CI: 3.14 to 4.37]) nor in proportion with adequate usage or overall commencement rate. However, at 12 months, there was a significant difference in hours of CPAP usage (SC: 2.50 hours/night [95% CI: 1.94 to 3.06] vs EV: 3.66 hours/night [95% CI: 2.92 to 4.40]). The probability of adequate CPAP usage at 12 months was higher in the intervention arm (odds ratio: 1.33; 95% CI: 1.04 to 1.7; P = .013). Patients with low education backgrounds benefitted substantially from the EV intervention compared with SC (mean difference at 12 months = 2.47 hours/night usage; 95% CI: 1.01 to 2.93; P < .01).

CONCLUSIONS

Low health literacy-designed EVs improve CPAP adherence at 12 months compared with SC, with the greatest impact in patients with a low educational background.

CLINICAL TRIAL REGISTRATION

Registry: Australian New Zealand Clinical Trials Registry; Name: Randomised controlled trial on the efficacy of audio-visual health educational materials on sleep health literacy and continuous positive airway pressure (CPAP) adherence in Sleep Clinic patients; URL: https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12619000523101; Identifier: ACTRN12619000523101.

CITATION

Ellender CM, Samaranayake C, Reid N, et al. Randomized controlled trial on the efficacy of audio-visual health educational materials on CPAP adherence: the AHEAD trial. J Clin Sleep Med. 2022;18(11):2617-2625.

Motivational Interviewing Effects on Positive Airway Pressure Therapy (PAP) Adherence: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

This systematic review and meta-analysis examined Motivational Interviewing (MI) effects on positive airway pressure (PAP) adherence and related outcomes.

METHOD

Medline, CIHANL, Psych Info, Web of Science, PubMed, and Cochrane Database of Systematic Reviews were searched for randomized controlled trials published from peer-reviewed journals in English from 1990 to 2021 that compared objective PAP adherence among adults with obstructive sleep apnea (OSA) in a MI and non-MI intervention. A random effects meta-analysis model was completed at the 1-to-2-week, and 1-, 2-, 3-, and 12-month follow-up, and risk of bias was analyzed with the Cochrane Risk of Bias Tool.

RESULTS

In 10 trials of naïve PAP users and one trial of non-naïve PAP users, 14 to 277 middle-aged adults with moderate-to-severe OSA generally engaged in a brief, individual, face-to-face, MI intervention with standard care or a control condition. Several trials of naïve PAP users demonstrated that MI increased PAP use 1-2.6 hours per night, but a similar number of trials showed comparable conditions. Secondary outcomes were mixed. Among non-naïve PAP users, MI did not significantly increase adherence or secondary outcomes. The meta-analysis of PAP-naïve participants revealed that MI had a small to moderate significant effect on PAP adherence at 1, 2, and 3 months after beginning PAP (Hedges' g = 0.38 to 0.48; 95% CI = 0.04, 0.75) compared to standard care alone.

CONCLUSIONS

Despite heterogeneity, MI moderately increased PAP adherence among PAP-naïve adults with moderate-to-severe OSA, suggesting an effective strategy for short-term (1-3 months) adherence.

Validation of the French Cues to CPAP Use Questionnaire in patients with OSAS: A step forward for evaluating cues to CPAP use in order to predict treatment adherence

PURPOSE

The cues to starting CPAP are important in patients with Obstructive Sleep Apnea Syndrome (OSAS) to predict CPAP use and behavioral change. The Cues to CPAP Use Questionnaire (CCUQ) is a short practical self-reported scale to evaluate such cues to action. This study sought to examine the psychometric reliability and validity of the French version.

METHODS

A forward-backward translation of the CCUQ was performed. Principal research tools were CCUQ, SEMSA and ESS. Subjects with OSAS were invited to complete the CCUQ just before CPAP initiation and 10 days after CPAP initiation. The ESS was completed just before CPAP initiation and one month after CPAP initiation. The SEMSA was completed just before CPAP initiation. Statistical analyses methods aim to evaluate the psychometric properties of the French CCUQ version in terms of its construct validity, internal structural validity, test-retest and external validity. Mean CPAP use on the previous month was recorded at one, six and twelve months after CPAP initiation.

RESULTS

A total of 140 patients with OSAS were included with 61.4% of men and a mean age of 55.3 (±12.9), BMI of 29.8 (±4.9), initial ESS of 11.97 (±5.68), and initial AHI 37.2/h (±19.3). Factor analysis confirmed the three-factor structure of the CCUQ. Cronbach's alpha coefficient was 0.64. Test-retest reliability (at t-0 and at 10 days) of the CCUQ was satisfactory. External validity shown significant correlation of the CCUQ with SEMSA and of the dimension "Partner cues" of the CCUQ with mean CPAP use at one month.

CONCLUSION

The French CCUQ scale is a reliable and valid tool for measuring cues to action in adults with OSAS initiating CPAP treatment. Further studies are necessary to confirm the predictive value of cues to action and self-efficacy for CPAP use and adherence. Such investigations would underpin public health CPAP interventions in accordance with models of behavioral change.

Correlates of Adherence of Multimodal Non-pharmacological Interventions in Older Adults With Mild Cognitive Impairment: A Cross-Sectional Study

Background

Non-pharmacological interventions are promising for delaying cognitive decline in older adults with mild cognitive impairment (MCI). Although some studies have demonstrated adherence rates and factors influencing participation in single modality non-pharmacological interventions, little is known about the level and correlates of adherence to multimodal non-pharmacological interventions (MNPIs) in older adults with MCI.

Objective

This study aimed to explore the adherence level and the correlates of adherence to MNPIs in older adults with MCI.

Methods

A cross-sectional design was employed. Community-dwelling older adults aged 60 years and over were recruited from senior community centers and healthcare centers in Huzhou from March 2019 to December 2020. Data were collected by a general information questionnaire and the adherence scale of cognitive dysfunction management (AS-CDM) in older adults with MCI. Hierarchical regression analyses were applied to explore the correlates of adherence to MNPIs.

Results

A total of 216 completed questionnaires were finally analyzed. Of these, 68.52% were female, and 45.4% of the participants had no less than 6 years of education. The overall mean score for adherence was 117.58 (SD = 10.51) out of 160, equivalent to 73.49 in the hundred-mark system, indicating a medium-level adherence to MNPIs in older adults with MCI. Of the five dimensions of adherence (AS-CDM), self-efficacy scored the highest, and the lowest was perceived barriers. The univariate analysis showed that the factors associated with the adherence to MNPIs were: regular physical exercise, meat-vegetable balance, absence of multimorbidity, high level of education, living alone, and living in urban (p < 0.05). In the hierarchical regression analysis, the final model explained 18.8% of variance in overall adherence (p < 0.01), which high school (Beta = 0.161, p < 0.05), college and above more (Beta = 0.171, p < 0.05), meat-vegetarian balance (Beta = 0.228, p < 0.05), regular physical exercise (Beta = 0.234, p < 0.05), and presence of multimorbidity (Beta = -0.128, p < 0.05) significantly contributed to adherence. In addition, nearly 80% of older adults with MCI preferred MNPIs.

Conclusion

Early assessment and management of adherence to MNPIs were essential in older adults with MCI. Furthermore, the findings shed light on several critical areas of intervention to improve adherence to MNPIs in older adults with MCI.

Clinical Trial Registration

http://www.chictr.org.cn/showproj.aspx?proj=35363, ChiCTR1900020950 (Registered on January 23, 2019).

The lived experience of adherence to asthma medication in young adults (18-34 years)

BACKGROUND

Adherence to asthma medications is commonly poor and is the primary cause for anticipated worsening health outcomes for patients with asthma. Worldwide, qualitative investigations that examine the adherence of young adults (18-34 years) to their asthma medication are limited.

METHOD

This study used a phenomenological research approach to explicate the experience of asthma medication adherence as described by young adults. Data were collected using semi-structured in-depth video interviews conducted with participants aged between 18 and 34 years to elicit their lived experience with adherence to asthma medication. Data from the interviews were transcribed and analyzed using the Edward and Welch (1) extension of Colaizzi's approach to phenomenology.

RESULTS

Results yielded four main themes related to the phenomenon of adherence that emerged from the analysis. The themes were: Having a plan; Having knowledge about your medication and asthma triggers; Being responsible with asthma medication; and Health belief.

CONCLUSION

According to the findings, for young people adhering to asthma medication is a process that depends on four vital aspects: (A) plan, (B) knowledge, (C) responsibility, and (D) belief. If young adults with asthma received individualized written asthma plans and have adequate knowledge about this plan, developing the correct health belief is likely to result. Hence, this can lead to a greater responsibility to manage their asthma to the recommended adherence level.

Continuous positive airway pressure adherence in people with obstructive sleep apnoea

OBJECTIVES

This cross-sectional study aimed to identify whether five factors of the health belief model were related to continuous positive airway pressure adherence in Thai people with obstructive sleep apnoea.

BACKGROUND

Obstructive sleep apnoea is a disorder impacting health, social wellbeing and the economy. Continuous positive airway pressure is a gold standard of treatment; however, poor adherence to treatment is an important issue that is related to a multiplicity of psychological and behavioural factors.

METHODS

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for cross-sectional studies was used to report the study. Purposive sampling was used to recruit 94 patients newly diagnosed with sleep apnoea and using CPAP devices from a sleep clinic. Participants completed a demographic record, the Thai versions of the Functional Outcomes of Sleep Questionnaire, the Perceived Barriers Questionnaire and the Self-Efficacy Measure for Sleep Apnea. CPAP adherence was measured by using information downloaded from the smart card of the devices. Data were analysed using descriptive statistics and logistic regression.

RESULTS

Only 54.3% of participants adhered to CPAP treatment using standard protocols. Perceived seriousness of their condition was significantly associated with CPAP adherence, whereas perceived susceptibility, benefits, barriers and self-efficacy were not.

CONCLUSIONS

We found a low rate of CPAP adherence among participants. The only factor related to CPAP adherence was perceived seriousness.

RELEVANCE FOR THE CLINICAL PRACTICE

With a low rate of CPAP adherence, healthcare professionals, especially nurses, should encourage patients to use CPAP regularly by providing them with support and education regarding the severity of the disease if untreated and the benefits of CPAP treatment on the disease. Healthcare professionals should be aware of psychological factors impacting patients' perception of sleep apnoea and CPAP treatment. Interventions dealing with these factors should be developed and implemented in practice.

The Effect of Rehospitalization and Emergency Department Visits on Subsequent Adherence to Weight Telemonitoring

BACKGROUND

Weight telemonitoring may be an effective way to improve patients' ability to manage heart failure and prevent unnecessary utilization of health services. However, the effectiveness of such interventions is dependent upon patient adherence.

OBJECTIVE

The purpose of this study was to determine how adherence to weight telemonitoring changes in response to 2 types of events: hospital readmissions and emergency department visits.

METHODS

The Better Effectiveness After Transition-Heart Failure trial examined the effectiveness of a remote telemonitoring intervention compared with usual care for patients discharged to home after hospitalization for decompensated heart failure. Participants were followed for 180 days and were instructed to transmit weight readings daily. We used Poisson regression to determine the within-person effects of events on subsequent adherence.

RESULTS

A total of 625 events took place during the study period. Most of these events were rehospitalizations (78.7%). After controlling for the number of previous events and discharge to a skilled nursing facility, the rate for adherence decreased by nearly 20% in the 2 weeks after a hospitalization compared with the 2 weeks before (adjusted rate ratio, 0.81; 95% confidence interval: 0.77-0.86; P < .001).

CONCLUSIONS

Experiencing a rehospitalization had the effect of diminishing adherence to daily weighing. Providers using telemonitoring to monitor decompensation and manage medications should take advantage of the potential "teachable moment" during hospitalization to reinforce the importance of adherence.

Development and Validation of the OSA-CPAP Perceived Competence Evaluation Interview

INTRODUCTION

Continuous positive airway pressure (CPAP) is one of the most common therapies for Obstructive Sleep Apnea (OSA). We present a brief, patient-reported outcome measure used to assess patients' levels of adherence with CPAP treatment.

METHODS

A questionnaire was developed based on academic literature. We qualitatively tested a pool of 18 items. It was tested in a sample of 174 patients from the Hospital La Princesa. Next, 1021 patients from Catalonia were evaluated.

RESULTS

5 items were removed. Nominal groups referred to three areas: general knowledge about OSA and its risks; CPAP treatment information and expectations; CPAP use, monitoring, and confidence with its use. The 13 retained items maintained the same meaning as the original questionnaire (r=.986; p<.001) and the three proposed dimensions detected a significant increase in general knowledge of OSA (t[173]=8.097, p<.001); CPAP treatment information (t[173]=15.170, p<.001); and CPAP use (t[173]=14.642, p<.001). The final 12-item version was reliable (CRI=.793) and its internal structure was adequate (χ²[51]=72.073; p=.027, CFI=.967, RMSEA=.020 [.000, .030]). Women had a better general knowledge of OSA (t[1,018]=2.190, p=.029), CPAP treatment information (t[1,018]=2.920, p=.004), and higher overall OSA-CPAP scores (t[1,018]=3.093, p=.002). Scores were positively related to quality of life and motivation, adherence was positively related to CPAP use and monitoring, and the total score was negatively related to daytime sleepiness.

CONCLUSIONS

The interview could help clinicians prevent some dropouts by targeting patients with lower adherence. It's a tool for assessing patient adherence to CPAP and to promote strategies through education and external motivational stimuli.

Obstructive Sleep Apnea: Treatment with Positive Airway Pressure

As in other adults, continuous positive airway pressure treatment for obstructive sleep apnea should be the mainstay of treatment. Benefits include improvements in sleepiness and quality of life, as well as improvements in hypertension control, arrhythmias, cardiovascular risk, and mortality. This article discusses issues in prescribing this treatment, including those related specifically to elderly individuals.

Development and psychometric evaluation of the Motivation to Use CPAP Scale (MUC-S) using factorial structure and Rasch analysis among patients with obstructive sleep apnea before CPAP treatment is initiated

BACKGROUND

Continuous positive airway treatment (CPAP) is first-line treatment for obstructive sleep apnea (OSA), but adherence tends to be low. A clinical tool focusing on motivation to use CPAP is missing. The purpose was to develop a brief questionnaire to assess motivation to use CPAP that is psychometrically robust and suitable for use in clinical practice.

METHODS

A convenience sample including 193 treatment naive patients with OSA (67% men; mean age = 59.7 years, SD 11.5) from two CPAP clinics was used. Clinical assessments and full night polygraphy were performed. Questionnaires administered before CPAP treatment included the newly developed Motivation to Use CPAP Scale (MUC-S), Minimal Insomnia Symptoms Scale (MISS), Epworth Sleepiness Scale (ESS), and Attitude towards CPAP treatment Inventory (ACTI). The validity and reliability of the MUC-S were investigated using Rasch and exploratory factor analysis models. Measurement invariance, dimensionality and differential item functioning (i.e., across gender groups, excessive daytime sleepiness (ESS), insomnia (MISS) and attitude towards CPAP (ACTI) groups) were assessed.

RESULTS

The results supported a two-factor solution (autonomous motivation, 6 items, factor loadings between 0.61 and 0.85 and controlled motivation, 3 items, factor loadings between 0.79 and 0.88) explaining 60% of the total variance. The internal consistency was good with Cronbach's alpha of 0.88 and 0.86 for the two factors. No differential item functioning was found. A latent class analysis yielded three profiles of patients with high (n = 111), moderate (n = 60) and low (n = 22) motivation. Patients with high motivation were older, had higher daytime sleepiness scores, more insomnia symptoms and a more positive attitude towards CPAP.

CONCLUSIONS

The MUC-S seems to be a valid tool with robust psychometric properties suitable for use at CPAP clinics. Future studies should focus on how motivation changes over time and if MUC-S can predict objective long-term CPAP adherence.

Experiences of Using Positive Airway Pressure for Treatment of Obstructive Sleep Apnoea: A Systematic Review and Thematic Synthesis

STUDY OBJECTIVES

Sub-optimal use of positive airway pressure (PAP) to treat obstructive sleep apnoea (OSA) continues to be a major challenge to effective treatment. Meanwhile, the individual and societal impacts of untreated OSA make effective treatment a priority. Although extensive research has been conducted into factors that impact PAP use, it is estimated that at least half of users do not use it as prescribed. However, the voice of users is notably minimal in the literature. A systematic review and qualitative metasynthesis of PAP user experience was conducted to contribute to understandings of how PAP is experienced and to inform how usage could be improved.

METHODS

PsycINFO, MEDLINE, CINAHL and EMBASE databases were systematically searched. Primary research findings of adult experiences using PAP that had been inductively analysed were included. Papers were critically appraised using the CASP qualitative checklist to generate a "hierarchy of evidence". Thematic synthesis was then conducted to generate analytical themes. Results were presented in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA).

RESULTS

25 papers reporting on over 398 people's experiences were analysed to generate 4 themes: Journey to PAP, Discomfort from and around PAP, Adapting to and using PAP, and Benefits from PAP. Author reflexivity and vulnerability to bias is acknowledged.

CONCLUSIONS

The findings highlight the applicability of a biopsychosocial understanding to PAP use. This metasynthesis gave voice to user experiences, revealing barriers to PAP use at a healthcare service level across the world, and suggests ways services can address these barriers.

Rural–urban drift: labour migration, health-seeking behaviour disparity in the urban slum of Madina, Ghana

Purpose

The health challenges that characterise most of the migrants' urban slums raises a lot of concern for their well-being. Health-seeking behaviour becomes an important step towards maintaining a healthy life. The importance of contextual issues is necessary to help meet specific community health needs and programmes. Therefore, this study aims to bridge the knowledge gap by investigating health-seeking behaviour disparity among rural–urban labour migrant's slum dwellers before and after migration to the urban slums of Madina in the Greater Accra Region, Ghana.

Design/methodology/approach

The author used explanatory sequential approach of research investigation. Questionnaire and interview guides were used to collect data from the respondents however, in the absence of an existing reliable sampling frame, the various communities were selected by the use of cluster sampling proportional to size. At the second stage, a simple random sampling was used to select the various household heads. A total of 241 questionnaires were retrieved from the respondents representing a response rate of 100%. The author used purposive sampling technique to conduct eight in-depth interviews and six key informants' interviews.

Findings

The author found various discrepancies in many of the activities that could fulfil substantial health-seeking behaviour in the slum as compared to migrant's places of origin. The reason for coming to the slum amidst many settlements needs and low education background are the factors that accounted for this. This study, therefore, contradicts the proposition held by the health belief model. It is, therefore, important to note that contextual issues are key, in this case, rural–urban migrant slums present a different dynamic that must be taken into account when designing health programmes for such settings.

Originality/value

Many, if not all the, studies on health-seeking behaviour have focused on urban slums without taking into account urban migrants' slums. Such a failure to take into account the variations of the health needs of migrants' urban slum settings can eventually lead to a mismatch of health programmes meant to address their challenges. Therefore, this study brings to the fore such variations that must be taken into account when designing health programmes. The study also indicates that even with the same people, there were disparities in terms of health-seeking behaviour in the slum and at places of origin.

Summary and Update on Behavioral Interventions for Improving Adherence with Positive Airway Pressure Treatment in Adults

Continuous positive airway pressure (PAP) is still the most efficacious treatment for obstructive sleep apnea when used effectively. Since the availability of PAP 39 years ago there have been considerable technological advances, such as quieter, lighter and smaller machines with better humidification. However, adherence to treatment is still a major problem. This article reviews studies published on behavioral interventions aimed at improving the uptake and maintenance of PAP treatment (January 2016-February 2020). It discusses underlying factors in the poor uptake and discontinuation of treatment and the role of qualitative research to better understand the perspective of the patients.

Utility of Multi-Theory Model (MTM) to Explain the Intention for PAP Adherence in Newly Diagnosed Sleep Apnea Patients

PURPOSE

The objective of this study was to assess the utility of a fourth-generation multi-theory model (MTM) in explaining the intention for initiation and sustenance of PAP adherence among newly diagnosed sleep apnea patients.

PATIENTS AND METHODS

For this cross-sectional study, data were collected at a private sleep center located in the Southeastern United States. A total of 138 newly diagnosed patients with sleep apnea who had been prescribed PAP therapy completed a valid and reliable 41-item MTM instrument. Stepwise multiple regression modeling was conducted to assess MTM based explanatory variables of PAP adherence in this study sample.

RESULTS

MTM constructs namely participatory dialogue (β = 0.17, p = 0.014), behavioral confidence (β = 0.48, p < 0.001), and changes in the physical environment (β = 0.26, p = 0.001) were statistically significant predictors of the intention for initiation of PAP therapy and accounted for 53.5% of the variance. Emotional transformation (β = 0.57, p < 0.001), changes in the social environment (β = 0.16, p = 0.016), and practice for change (β = 0.16, p = 0.047) were statistically significant predictors of the intention for sustenance of PAP therapy and accounted for 60.6% of the variance.

CONCLUSION

The MTM was found to be a promising theoretical model in explaining the intention for initiation and sustenance of PAP therapy.

Development and Validation of the OSA-CPAP Perceived Competence Evaluation Interview

INTRODUCTION

Continuous positive airway pressure (CPAP) is one of the most common therapies for Obstructive Sleep Apnea (OSA). We present a brief, patient-reported outcome measure used to assess patients' levels of adherence with CPAP treatment.

METHODS

A questionnaire was developed based on academic literature. We qualitatively tested a pool of 18 items. It was tested in a sample of 174 patients from the Hospital La Princesa. Next, 1021 patients from Catalonia were evaluated.

RESULTS

5 items were removed. Nominal groups referred to three areas: general knowledge about OSA and its risks; CPAP treatment information and expectations; CPAP use, monitoring, and confidence with its use. The 13 retained items maintained the same meaning as the original questionnaire (r=.986; p<.001) and the three proposed dimensions detected a significant increase in general knowledge of OSA (t[173]=8.097, p<.001); CPAP treatment information (t[173]=15.170, p<.001); and CPAP use (t[173]=14.642, p<.001). The final 12-item version was reliable (CRI=.793) and its internal structure was adequate (χ²[51]=72.073; p=.027, CFI=.967, RMSEA=.020 [.000, .030]). Women had a better general knowledge of OSA (t[1,018]=2.190, p=.029), CPAP treatment information (t[1,018]=2.920, p=.004), and higher overall OSA-CPAP scores (t[1,018]=3.093, p=.002). Scores were positively related to quality of life and motivation, adherence was positively related to CPAP use and monitoring, and the total score was negatively related to daytime sleepiness.

CONCLUSIONS

The interview could help clinicians prevent some dropouts by targeting patients with lower adherence. It's a tool for assessing patient adherence to CPAP and to promote strategies through education and external motivational stimuli.

Adaptive servo-ventilation in patients with chronic heart failure and sleep disordered breathing: predictors of usage

PURPOSE

Adaptive servo-ventilation (ASV) is a therapy designed for patients with central sleep apnea (CSA) and Cheyne Stokes respiration. The aim of this study was to find predictors of ASV usage in patients with CSA in a routine sleep clinic cohort.

METHODS

In this retrospective study, consecutive patients in whom ASV therapy was initiated at the University Hospital Regensburg between 2011 and 2015, were analyzed. Analysis included polysomnographies of diagnostic and ASV initiation nights, a phone questionnaire on ASV usage, readout of the ASV device 1 month after initiation ("early ASV usage," 1 month after ASV initiation), and the readout of the last month before a reappointment date set in 2015 ("late ASV usage," median 17 months after ASV initiation).

RESULTS

In 69 consecutive patients, the mean early and late ASV usage per night was 4.8 ± 2.5 h and 4.1 ± 3.0 h, respectively. Seventeen months after initiation, 57% of patients used the device ≥ 4 h per night, and of those 91% reported a subjective benefit from ASV therapy. Early ASV usage was significantly associated with late ASV usage (univariable regression: Beta 0.8, 95%CI [0.6; 1.0] p < 0.001). In multivariable regression analysis, short duration of slow wave sleep (N3) during diagnostic polysomnography (Beta - 6.2, 95%CI [- 11.0; - 1.5]; p = 0.011) and subjective benefit from ASV (Beta 174.0, 95%CI [68.6; 279.5]; p = 0.002) were significantly associated with longer late ASV usage.

CONCLUSION

Early ASV usage predicts late ASV usage. In addition, low slow wave sleep before ASV initiation and subjective benefit from ASV may contribute to higher late ASV usage.

A Tailored Motivational Messages Library for a Mobile Health Sleep Behavior Change Support System to Promote Continuous Positive Airway Pressure Use Among Patients With Obstructive Sleep Apnea: Development, Content Validation, and Testing

BACKGROUND

Continuous positive airway pressure (CPAP) therapy is the most effective treatment for obstructive sleep apnea (OSA). Despite the reported benefits of CPAP therapy in treating OSA, its effectiveness is reduced by less-than-optimal adherence or use. Up to 50% of patients who accept CPAP therapy fail to adhere to it. As a lack of commitment to CPAP therapy is one of the most significant factors that hinder OSA treatment effectiveness, patient motivation and education are critical to help alleviate the problem of poor CPAP adherence or use.

OBJECTIVE

This study aims to support the development of mobile health interventions or information systems solutions to promote CPAP adherence and use among patients with OSA through development, content validation, and testing of tailored motivational messages.

METHODS

In phase 1, an initial library of 60 messages was developed to promote CPAP use among patients with OSA. In phase 2, draft messages were evaluated for content validation testing for relevance and clarity by research and clinical experts. In phase 3, patients with OSA (N=24) were recruited through a Qualtrics panel to rate the perceived persuasiveness of the messages in terms of threat and efficacy perceptions, as per their computed extended parallel process model (EPPM) response states. The average score of the ratings was calculated for each message. The messages were sorted according to their average (from highest to lowest) to select the best 12 messages for each tailored set based on the potential responses from the EPPM.

RESULTS

In phase 1, 60 messages were developed based on the existing literature and a review of existing materials. In phase 2, the enumerated content validity of the messages was established through the use of the content validity index for items. A total of 57 messages were found to have acceptable content relevance and clarity. In phase 3, patients with OSA perceived the final library of 48 messages to be persuasive.

CONCLUSIONS

After the process of content validation and testing, the final library of messages met the criteria for clarity, relevance, and perceived persuasiveness. This study emphasizes the importance of developing and validating the content of motivational messages, grounded in EPPM theory, across the 4 possible response states in terms of high or low efficacy and threat perceptions.

Self-efficacy Mediates Perceived Benefits and Barriers of Adherence of Heroin-dependent Patients to Methadone for Addiction Treatment: A Health Belief Model Study

OBJECTIVE

Although methadone for addiction treatment (MAT) has been widely used in China, the low adherence rate in MAT clinics poses a great challenge. We aimed to investigate the factors related to the adherence of heroin-dependent patients to MAT based on the Health Belief Model (HBM) in Sichuan, China.

METHODS

A cross-sectional structured interview was conducted between August and November 2018. Stratified multi-stage sampling was carried out. A total of 581 participants were enrolled from 5 clinics and completed the face-to-face structured interview. Univariate, adjusted logistic regression, multivariate logistic regression analysis and the structural equation modeling (SEM) were employed to explore the association between constructs of HBM and adherence to MAT among heroin-dependent patients.

RESULTS

The adherence rate of MAT was 79.3% in the past 6 months. Among all constructs of HBM, self-efficacy (AOR: 1.16, 95% CI: 1.10, 1.22), perceived benefits (AOR: 1.05, 95% CI: 1.00, 1.10) and perceived barriers (AOR: 0.87, 95% CI: 0.77, 0.98) were associated with adherence to MAT. Self-efficacy was directly associated with adherence to MAT (β = 0.347, P < 0.05). Perceive benefits (β = 0.276, P < 0.01) and perceived barriers (β = -0.241, P < 0.05) were directly associated with self-efficacy. However, perceived benefits (β = 0.096, P < 0.01) and perceived barriers (β = -0.084, P < 0.01) were only indirectly associated with adherence to MAT.

CONCLUSION

The adherence of heroin-dependent patients to MAT can be explained by self-efficacy, perceived benefits and barriers. Self-efficacy plays a significant role as a mediating variable. Future interventions should be considered to improve patients' self-efficacy to MAT.

Application of health behaviour theory to sleep health improvement

Although sleep hygiene is often used for broad sleep health promotion efforts, sleep hygiene education programmes are largely ineffective. These programmes are limited by their lack of a theoretical foundation. Health behaviour theory (HBT) has been used for decades to successfully predict and modify many health behaviours, but its use in the study of sleep health is rare. The purpose of this review is threefold. First, four dominant HBTs will be introduced. Second, the brief literature on HBT and sleep health will be reviewed. Lastly, a translational research agenda will be proposed. The present review concludes that HBT shows potential in both the prediction and modification of sleep health, and that there are several short- and long- term research goals to advance these efforts.

Prevention of Morbidity in Sickle Cell Disease (POMS2a)-overnight auto-adjusting continuous positive airway pressure compared with nocturnal oxygen therapy: a randomised crossover pilot study examining patient preference and safety in adults and children

DESIGN

This randomised crossover trial compared nocturnal auto-adjusting continuous positive airway pressure (APAP) and nocturnal oxygen therapy (NOT) in adults and children with sickle cell anaemia, with patient acceptability as the primary outcome. Secondary outcomes included pulmonary physiology (adults), safety, and daily pain during interventions and washout documented using tablet technology.

METHODS

Inclusion criteria were age > 8 years and the ability to use an iPad to collect daily pain data. Trial participation was 4 weeks; week 1 involved baseline data collection and week 3 was a washout between interventions, which were administered for 7 days each during weeks 2 and 4 in a randomised order. Qualitative interviews were transcribed verbatim and analysed for content using a funnelling technique, starting generally and then gaining more detailed information on the experience of both interventions. Safety data included routine haematology and median pain days between each period. Missing pain day values were replaced using multiple imputation.

RESULTS

Ten adults (three female, median age 30.2 years, range 18-51.5 years) and eleven children (five female, median age 12 years, range 8.7-16.9 years) enrolled. Nine adults and seven children completed interviews. Qualitative data revealed that the APAP machine was smaller, easier to handle, and less noisy. Of 16 participants, 10 preferred APAP (62.5%, 95% confidence interval (CI) 38.6-81.5%). Haemoglobin decreased from baseline on APAP and NOT (mean difference -3.2 g/L (95% CI -6.0 to -0.2 g/L) and -2.5 g/L (95% CI -4.6 to 0.3 g/L), respectively), but there was no significant difference between interventions (NOT versus APAP, 1.1 (-1.2 to 3.6)). Pulmonary function changed little. Compared with baseline, there were significant decreases in the median number of pain days (1.58 for APAP and 1.71 for NOT) but no significant difference comparing washout with baseline. After adjustment for carry-over and period effects, there was a non-significant median difference of 0.143 (95% CI -0.116 to 0.401) days additional pain with APAP compared with NOT.

CONCLUSION

In view of the point estimate of patient preference for APAP, and no difference in haematology or pulmonary function or evidence that pain was worse during or in washout after APAP, it was decided to proceed with a Phase II trial of 6 months APAP versus standard care with further safety monitoring for bone marrow suppression and pain.

TRIAL REGISTRATION

ISRCTN46078697 . Registered on 18 July 2014.

Quality of Life in Youth With Obstructive Sleep Apnea Syndrome (OSAS) Treated With Continuous Positive Airway Pressure (CPAP) Therapy

OBJECTIVE/BACKGROUND

Improvement is sought for youth with obstructive sleep apnea syndrome (OSAS) who have poor quality of life (QoL), which resolves somewhat following treatment. One mitigating factor in improved QoL following treatment may be adherence to the CPAP protocol, which presents a barrier to most youth. This study explored relations between CPAP adherence and QoL in youth with OSAS.

PARTICIPANTS

We recruited 42 youth-caregiver dyads in which youth between the ages of 8 and 16 years were diagnosed with OSAS and required CPAP use as part of their treatment plan.

METHODS

Following diagnosis of OSAS requiring treatment with CPAP therapy, caregivers completed baseline measures of OSAS-specific QoL. The OSAS-specific QoL domains assessed included sleep disturbance, physical symptoms, emotional distress, daytime function, and caregiver concern. Families received routine CPAP care for three months, after which caregivers again completed measures of OSAS-specific QoL. Adherence data were collected from smartcards within the CPAP machine after three months of treatment.

RESULTS

Fifteen youth were adherent to CPAP therapy and 10 were not adherent. CPAP-adherent youth demonstrated significant changes in two domains of OSAS-specific QoL when compared to nonadherent youth: decreased sleep disturbance and decreased caregiver concern.

CONCLUSIONS

CPAP adherence appears to be associated with positive changes in OSAS-specific QoL domains. It will be important for future research and clinical work to examine strategies for improving CPAP adherence in youth with OSAS.

Predictors of Noncompliance to Antihypertensive Therapy among Hypertensive Patients Ghana: Application of Health Belief Model

This study determined noncompliance to antihypertensive therapy (AHT) and its associated factors in a Ghanaian population by using the health belief model (HBM). This descriptive cross-sectional study conducted at Kintampo Municipality in Ghana recruited a total of 678 hypertensive patients. The questionnaire constituted information regarding sociodemographics, a five-Likert type HBM questionnaire, and lifestyle-related factors. The rate of noncompliance to AHT in this study was 58.6%. The mean age (SD) of the participants was 43.5 (±5.2) years and median duration of hypertension was 2 years. Overall, the five HBM constructs explained 31.7% of the variance in noncompliance to AHT with a prediction accuracy of 77.5%, after adjusting for age, gender, and duration of condition. Higher levels of perceived benefits of using medicine [aOR=0.55(0.36-0.82),p=0.0001] and cue to actions [aOR=0.59(0.38-0.90),p=0.0008] were significantly associated with reduced noncompliance while perceived susceptibility [aOR=3.05(2.20-6.25), p<0.0001], perceived barrier [aOR=2.14(1.56-2.92), p<0.0001], and perceived severity [aOR=4.20(2.93-6.00),p<0.0001] were significantly associated with increased noncompliance to AHT. Participant who had completed tertiary education [aOR=0.27(0.17-0.43), p<0.0001] and had regular source of income [aOR=0.52(0.38-0.71), p<0.0001] were less likely to be noncompliant. However, being a government employee [aOR=4.16(1.93-8.96), p=0.0002)] was significantly associated increased noncompliance to AHT. Noncompliance to AHT was considerably high and HBM is generally reliable in assessing treatment noncompliance in the Ghanaian hypertensive patients. The significant predictors of noncompliance to AHT were higher level of perceived barriers, susceptibility, and severity. Intervention programmes could be guided by the association of risk factors, HBM constructs with noncompliance to AHT in clinical practice.

Specific insomnia symptoms and self-efficacy explain CPAP compliance in a sample of OSAS patients

This study explores the association between specific insomnia symptoms (sleep onset, sleep maintenance and early morning awakenings symptoms) and self-efficacy (perceived self-confidence in the ability to use CPAP) with CPAP compliance in French patients with obstructive sleep apnea syndrome (OSAS). We performed a retrospective, cross-sectional analysis of CPAP compliance in a cohort of 404 patients diagnosed with OSAS. Patients completed mailed questionnaires on sleepiness (ESS), insomnia (ISI) and self-efficacy in sleep apnea (SEMSA). Linear regression modeling analyses were performed to explore the impact of measured variables on the number of hours of CPAP use. Of the initial pool of 404 patients, 288 returned the questionnaires (71% response rate). Their mean age was 63.16±12.73 yrs, 31% were females, mean BMI was 30.39±6.31 kg/m2, mean daily CPAP use was 6.19±2.03 h, mean number of years of use was 6.58±6.03 yrs, and mean initial AHI before CPAP use was 34.61±20.71 /h. Age (p<0.01), BMI (p<0.01), sleep onset insomnia symptoms (p<0.01), sleep maintenance insomnia symptoms (p<0.01) and self-efficacy (p<0.01) were significantly associated with mean daily CPAP use. We found that specific insomnia symptoms and self-efficacy were associated with CPAP compliance. Our findings underline the need to demonstrate that interventions that reduce insomnia symptoms and improve self-efficacy will increase CPAP compliance.

Promoting CPAP adherence in clinical practice: A survey of Swedish and Norwegian CPAP practitioners' beliefs and practices

The benefits of continuous positive airway pressure (CPAP) treatment for obstructive sleep apnea are well established, but adherence tends to be low. Research exploring CPAP practitioners' beliefs around determinants of CPAP adherence, and the actions they use in clinical practice to promote CPAP adherence is lacking. This study aimed to: (i) develop and validate a questionnaire to assess beliefs and current practices among CPAP practitioners; (ii) explore practitioners' beliefs regarding the main determinants of patient adherence, and the actions practitioners most commonly use to promote CPAP adherence; and (iii) explore the associations between perceived determinants and adherence-promotion actions. One-hundred and forty-two CPAP practitioners in Sweden and Norway, representing 93% of all Swedish and 62% of all Norwegian CPAP centres, were surveyed via a questionnaire exploring potential determinants (18 items) and adherence-promotion actions (20 items). Confirmatory factor analysis and second-order structural equational modelling were used to identify patterns of beliefs, and potential associations with adherence-promotion actions. Patients' knowledge, motivation and attitudes were perceived by practitioners to be the main determinants of CPAP adherence, and educating patients about effects, management and treatment adjustments were the most common practices. Knowledge was shown to predict educational and informational actions (e.g. education about obstructive sleep apnea and CPAP). Educational and informational actions were associated with medical actions (e.g. treatment adjustment), but knowledge, attitude and support had no association with medical actions. These findings indicate that a wide variety of determinants and actions are considered important, though the only relationship observed between beliefs and actions was found for knowledge and educational and informational actions.

[Importance of the emotional dimension when providing information to patients with obstructive sleep apnea syndrome]

INTRODUCTION

To promote adaptation to treatment with continuous positive airway pressure, an information document was developed for people starting their treatment with continuous positive airway pressure.

METHODS

Seven patients with obstructive sleep apnea took part in a focus group. This allowed the identification both of useful information and the best way that this information could be presented.

RESULTS

The key specific information objectives and the best emotional register to use were as follows: (1) develop awareness about the physiological mechanisms and consequences that can occur from obstructive sleep apnea syndrome, using formulations arousing fear, (2) enable the recognition of the symptoms, risk factors and chronicity of this syndrome, (3) reassure and motivate the patient about treatment with continuous positive airway pressure.

CONCLUSIONS

To promote adaptation to positive airway pressure in early care, combining different emotional tones is preferable, mixing both fear and reassurance.

Obstructive sleep apnea: current perspectives

The prevalence of obstructive sleep apnea (OSA) continues to rise. So too do the health, safety, and economic consequences. On an individual level, the causes and consequences of OSA can vary substantially between patients. In recent years, four key contributors to OSA pathogenesis or "phenotypes" have been characterized. These include a narrow, crowded, or collapsible upper airway "anatomical compromise" and "non-anatomical" contributors such as ineffective pharyngeal dilator muscle function during sleep, a low threshold for arousal to airway narrowing during sleep, and unstable control of breathing (high loop gain). Each of these phenotypes is a target for therapy. This review summarizes the latest knowledge on the different contributors to OSA with a focus on measurement techniques including emerging clinical tools designed to facilitate translation of new cause-driven targeted approaches to treat OSA. The potential for some of the specific pathophysiological causes of OSA to drive some of the key symptoms and consequences of OSA is also highlighted.

Barriers to acceptance and adherence to continuous positive airway pressure therapy in patients with obstructive sleep apnea: a report from Kermanshah province, western Iran

PURPOSE

Continuous positive airway pressure (CPAP) is the gold standard treatment for obstructive sleep apnea (OSA). CPAP acceptance and adherence are critical issues for optimal treatment outcome. Identifying barriers to acceptance and adherence can improve intervention development and outcomes. This study aimed to investigate the barriers to CPAP acceptance/adherence in patients with OSA in western Iran.

PATIENTS AND METHODS

Patients with OSA, who had been prescribed CPAP by the Sleep Disorders Research Center of Kermanshah University of Medical Sciences, were recruited. They were interviewed via telephone regarding acceptance (ie, CPAP use during the first 2 weeks) and adherence (ie, CPAP use 4 h/d for 70% of the nights per week). Barriers to acceptance and adherence were solicited.

RESULTS

Out of a possible sample of 101, 97 patients (79 male) were reached and included in the study. They had a mean age of 48.76 years (SD =12.04) and mean apnea/hypopnea index score of 36.06 (SD =1.87). Patients were categorized into the following acceptance/adherence groups: nonacceptance (CPAP not purchased; 72.2%), poor adherence (5.2%), and adherent (22.7%). Inability to afford a CPAP device, perception of symptom reduction/no need for treatment, and dissatisfaction with treatment were among the most common reasons for nonacceptance and poor adherence.

CONCLUSION

CPAP acceptance and adherence in western Iran are low. Approximately 70% of the patients did not accept CPAP treatment (due to not obtaining the device) and 5% did not adhere. To improve acceptance/adherence, increased access (ie, reduced cost or increased insurance coverage) and enhanced education about the benefits of the treatment are recommended. Treatment monitoring via regular follow-ups may also prove beneficial.

Self-Efficacy and Short-Term Adherence to Continuous Positive Airway Pressure Treatment in Children

Study Objectives

Infants, children, and adolescents are increasingly being prescribed continuous positive airway pressure (CPAP) for treatment of obstructive sleep apnea syndrome (OSAS), yet adherence is often poor. The purpose of this study was to examine the relationship between caregiver and patient-reported health cognitions about CPAP prior to starting CPAP and CPAP adherence at 1 month. We hypothesized that greater caregiver-reported self-efficacy would be positively associated with CPAP adherence in children. We also evaluated patient-reported self-efficacy and caregiver- and patient-reported risk perception and outcome expectations as they related to adherence, as well as how demographic factors influenced these relationships.

Methods

A pediatric modification of the Self-Efficacy Measure for Sleep Apnea Questionnaire was administered to children and adolescents with OSAS-prescribed CPAP and their caregivers during the clinical CPAP-initiation visit. The primary outcome variable for adherence was the average total minutes of CPAP usage across all days from the date that CPAP was initiated to 31 days later.

Results

Unadjusted ordinary least-square regression showed a significant association between caregiver-reported self-efficacy and adherence (p = .007), indicating that mean daily CPAP usage increased by 48.4 minutes when caregiver-reported self-efficacy increased by one point (95% confidence interval 13.4-83.4 minutes). No other caregiver- or patient-reported cognitive health variables were related to CPAP use.

Conclusions

This study indicates that caregiver CPAP-specific self-efficacy is an important factor to consider when starting youth on CPAP therapy for OSAS. Employing strategies to improve caregiver self-efficacy, beginning at CPAP initiation, may promote CPAP adherence.

Effects of respiratory muscle training (RMT) in patients with mild to moderate obstructive sleep apnea (OSA)

PURPOSE

Different forms of training focusing on the muscles of the upper airways showed limited effects on obstructive sleep apnea (OSA) and/or snoring. We investigated the effect of generalized respiratory muscle training (RMT) in lean patients with mild to moderate OSA.

METHODS

Nine male subjects (52.0 ± 10.8 years, BMI 29.1 ± 2.1 kg/m²) with obstructive sleep apnea (apnea-hypopnea index (AHI) 9-29) participated in an open, single-arm pilot study. After a 1-week build-up phase, patients underwent 4 weeks of normocapnic hyperpnea RMT five times a week for 30 min each. The initial and final measurements comprised polysomnography, pulmonary function tests, Epworth sleepiness scale (ESS), and SF-36 questionnaire (quality of life (QoL) self-assessment). The investigational site was a university-affiliated hospital for pulmonary diseases and sleep medicine, Solingen/Germany.

RESULTS

Patients trained effectively, seen by a significant (p < 0.01) increase of breathing frequency (23.3 ± 1.5 /min vs. 30.6 ± 2.9 /min) and minute volume (81.2 ± 13.7 L vs. 109.1 ± 21.9 L). AHI, snoring and ESS remained unchanged after training. QoL as measured by SF-36 significantly (p < 0.05) improved after the training in the subscales "bodily pain" (79 ± 21 vs. 90 ± 12) and "change of health" (3.1 ± 0.3 vs. 2.4 ± 0.5).

CONCLUSIONS

There is no evidence that AHI, pulmonary function or daytime sleepiness are affected by 5 weeks of RMT. Nevertheless, there is an improvement of parameters of quality of life.

TRIAL REGISTRATION

ClinicalTrials.gov , register no. NCT 00936286.

Understanding Treatment Adherence With the Health Belief Model in Children With Cystic Fibrosis

Objective. Children’s health beliefs are significantly related to their adherence; however, pediatric literature has rarely tested health-related theories as a whole. The goal of the present study was to evaluate the use of the health belief model (HBM) in understanding children’s adherence, both globally and to individual treatment components. Method. Thirty-three patient–parent dyads completed questionnaires regarding health beliefs and adherence to medical regimens. Results. Multiple linear regressions found a significant relationship among the HBM variables and reports of global adherence for children and parents. For children, the HBM variables were significantly related to adherence to aerosol medications, aerosol antibiotics, metered dose inhalers, and vitamins. For parents, the HBM variables were significantly related to children’s adherence to airway clearance, oral antibiotics, and vitamins. Paired sample t tests found children and parents had significantly discrepant heath beliefs. Conclusion. These findings provide further support for the HBM in evaluating pediatric adherence, with evidence that barriers and cues to action may be targets for early intervention. Future research using this model to identify a comprehensive way to assess, understand, and elicit change in the adherence to medical regimens for youth with chronic illness would be beneficial.

Development and validation of CF-Medication Beliefs Questionnaire: A mixed-methods approach

BACKGROUND

Beliefs about medication have been associated with adherence in other diseases but there are no existing disease-specific medication beliefs questionnaires for CF. This mixed-methods validated the Cystic Fibrosis Medication Belief Questionnaire (CF-MBQ), based on social cognitive theory.

METHODS

Based on previous research, items were developed for five domains: motivation, self-efficacy, perceived importance, and decisional balance to take or miss medications. Cognitive interviews were conducted with 15 adult patients with CF to refine item development. 128 patients with CF completed an online survey and objective medication adherence was measured using pharmacy refill data.

RESULTS

The five subscales demonstrated strong psychometric properties, with adequate-to-good internal consistency scores. More importantly, each domain demonstrated construct validity with adherence.

CONCLUSIONS

These theoretically-derived measures may be important for clinical purposes to provide guidance on appropriate interventions to improve adherence and for research to provide enhanced understanding on patient determinants of medication adherence.

CPAP Treatment Adherence in Women with Obstructive Sleep Apnea

Untreated obstructive sleep apnea (OSA) has numerous negative health-related consequences. Continuous positive airway pressure (CPAP) is generally considered the treatment of choice for OSA, but rates of nonadherence are high. It is believed that OSA is more prevalent among men; therefore understanding how OSA presents among women is limited and treatment adherence has received little research attention. For this study, 29 women were recruited from primary care offices. They completed a questionnaire battery and underwent a night of nocturnal polysomnography (PSG) followed by a visit with a sleep specialist. Women diagnosed with OSA were prescribed CPAP; 2 years later CPAP adherence was evaluated. Results show that approximately half the sample was adherent. There were no significant differences between adherent and nonadherent women on OSA severity; however CPAP adherent women had worse nocturnal and daytime functioning scores at the time of diagnosis. Moreover, when the seven nocturnal and daytime variables were used as predictors in a discriminant analysis, they could predict 87% of adherent and 93% of the nonadherent women. The single most important predictor was nonrefreshing sleep. We discuss the implications of the findings for identifying women in primary care with potential OSA and offer suggestions for enhancing treatment adherence.

Patient-centered care in obstructive sleep apnea: A vision for the future

Obstructive sleep apnea is a common condition, with multiple potential neurocognitive, cardiovascular, and metabolic consequences. Efficacious treatment is available, but patient engagement is typically required for treatment to be effective. Patients with sleep apnea are phenotypically diverse and have individual needs, preferences, and values that impact treatment decisions. There has been a shift in obstructive sleep apnea management from diagnosis to chronic care management. Making treatment decisions that incorporate an individual patient's values and preferences and are personalized for that patient's biology has the potential to improve patient outcomes. A patient-centered care approach in obstructive sleep apnea is reviewed including 1) determining patient-specific needs to guide treatment decisions, 2) understanding patient values, preferences, and other factors impacting treatment decisions and using shared decision-making, 3) enhancing patient education and support to improve treatment adherence, 4) promoting patient engagement, 5) optimizing care coordination, continuity of care, and access to care, and 6) determining and assessing patient-centered outcomes.

Impact of Randomization, Clinic Visits, and Medical and Psychiatric Cormorbidities on Continuous Positive Airway Pressure Adherence in Obstructive Sleep Apnea

STUDY OBJECTIVES

To evaluate factors associated with continuous positive airway pressure (CPAP) adherence in patients with obstructive sleep apnea (OSA) in the Apnea Positive Pressure Long-term Efficacy Study (APPLES) cohort.

METHODS

The data from a prospective 6-mo multicenter randomized controlled trial with 558 subjects randomized to active CPAP and 547 to sham CPAP were analyzed to assess adherence to CPAP during first 2 mo (early period) and during months 5-6 (late period).

RESULTS

Participants randomized to active CPAP had higher hours of nightly adherence compared to the sham CPAP group at both 2 (4.9 ± 2.0 h versus 4.07 ± 2.14 h, p < 0.001) and 6 mo (4.70 ± 2.08 h versus 3.41 ± 2.19 h, p < 0.001). Those assigned to sham CPAP were more likely to correctly identify their treatment group (70.0% versus 55.2%, p < 0.001). Irrespective of treatment group assignment, those who believed they were receiving active CPAP had higher hours of adherence than those who thought they were in the sham CPAP group at both 2 mo (4.91 ± 2.01 versus 4.17 ± 2.17, p < 0.001) and 6 mo (4.65 ± 2.10 versus 3.65 ± 2.22, p < 0.001). Among those randomized to active CPAP, older age was significantly related to CPAP use > 4 h per night. Presence of cardiovascular disorders was associated with higher hours of CPAP use, whereas presence of anxiety was associated with a trend toward lower hours of CPAP use. Presence of nasal congestion was associated with a decrease in mean daily CPAP use between the early and the late adherence period. The adherence during the week prior to a clinic visit was higher than the average adherence during the 2-mo period prior to the visit.

CONCLUSIONS

Randomization to active therapy, belief that one is in the active treatment group, older age, and possibly presence of cardiovascular disorders are positively linked to CPAP adherence. Nasal congestion and anxiety are negatively associated with CPAP adherence. CPAP nightly usage increases as clinic visits approach.

The Effect of Patient Neighborhood Income Level on the Purchase of Continuous Positive Airway Pressure Treatment among Patients with Sleep Apnea

RATIONALE

The cost of continuous positive airway pressure (CPAP) treatment for patients with low socioeconomic status may be an important barrier to successful treatment of obstructive sleep apnea under a copayment health care system.

OBJECTIVES

We evaluated an association between patient neighborhood income level and the purchase of a CPAP device under a cost-sharing health care insurance system.

METHODS

All adults who underwent a first diagnostic sleep study at St. Michael's Hospital (Toronto, ON, Canada) between 2004 and 2010 were included. Severity of obstructive sleep apnea was determined by the apnea-hypopnea index (AHI) and level of daytime sleepiness (by the Epworth Sleepiness Scale). Patient data were linked to provincial health administrative data from 1991 to 2013 to determine the purchase of CPAP equipment, comorbidities, neighborhood income, and rural status at baseline. Neighborhood income was categorized into quintiles, ranked from poorest (Q1) to wealthiest (Q5). Assuming that the majority of participants with severe obstructive sleep apnea (AHI > 30 events/h) and excessive daytime sleepiness (Epworth Sleepiness Scale ≥ 10) would have been strongly recommended CPAP, we evaluated the association between patient neighborhood income and purchase of a CPAP device in this group via multivariable Cox regressions.

MEASUREMENTS AND MAIN RESULTS

Of the 695 participants with severe obstructive sleep apnea and excessive daytime sleepiness, 400 (58%) purchased a CPAP device. Patients who accepted CPAP were more likely to live in a higher-income neighborhood. Cumulative incidence of CPAP acceptance at 6 months was 43% for individuals in a low-income neighborhood (Q1) and 52% in combined higher-income neighborhoods (Q2-5) (P = 0.05). Controlling for sex and age, living in higher-income neighborhoods was associated with a 27% increased chance of accepting CPAP compared with the lowest-income neighborhood (hazard ratio Q2-5 vs. Q1, 1.27; 95% confidence interval, 0.98-1.64; P = 0.07).

CONCLUSIONS

Living in an unfavorable neighborhood is not an obstacle to CPAP treatment among symptomatic patients with severe obstructive sleep apnea under a copayment health care system. However, a potential 27% improvement in CPAP acceptance associated with higher neighborhood income is not inconsequential. Also, the overall CPAP acceptance rate was relatively low, suggesting that obstacles other than finances are primarily responsible.