As a Respiratory Therapist who works in homecare, I work primarily with the diagnosis and treatment of sleep disordered breathing. The most common sleep disorder that I see would be Obstructive Sleep Apnea (OSA). OSA is a sleep disorder "caused by repeated episodes of upper airway collapse and obstruction during sleep associated with arousal from sleep" (Rundo, 2019). The issue with OSA is that it "is associated with a number of comorbid conditions" (Rundo, 2019). These conditions range from cardiovascular in nature to mental illness and metabolic disorders. So why then is long-term adherence to treatment so low among these patients? Wolkove et al. (2008) report that 46% of patients either stopped using therapy or never started to begin with. The social-ecological model (SEM) of health can help to explain the different levels of influence on patient adherence to CPAP therapy. The Centers for Disease Control and Prevention (CDC) describes the SEM as "the complex interplay between individual, relationship, community and societal factors" (CDC, 2022).
To help explain the individual level of the SEM, the Health Belief Model (HBM) can be used. The HBM was "developed in an effort to explain the widespread failure of people to participate in programmes to prevent or to detect disease" (Baum et al., 1997, p. 113). This model looks at the "patient's perceived risk of negative health outcomes and perceived severity of the disorder, as well as their weighing of potential benefits and barriers"(Olsen et al., 2008). So, in other words, does the burden of wearing a CPAP machine outweigh the benefits that come along with it? Is the risk of cardiovascular disease, diabetes, mental illness, etc., perceived to be high enough to address the sleep apnea diagnosis? A study conducted "suggests that patients have developed beliefs and expectations about obstructive sleep apnoea and continuous positive airway pressure even before they try continuous positive airway pressure treatment." (Olsen et al., 2008). I see this in my own practice as well. It is not uncommon for a patient to arrive in my office in a negative headspace about therapy. This may be due to the fact that they feel pressured by a spouse or physician or that they are imagining the worst case scenario for noise levels and mask discomfort. Olsen et al. (2008) have determined, using the HBM, that "benefits and barriers were found to be better predictors of CPAP adherence than the objective severity measures". So, in other words, negative attitude towards therapy is more powerful in adherence to therapy than the diagnosis itself. I can also attest to this and I tell my patients often that severity of illness is not necessarily going to align with severity of symptoms. It is entirely possible for a patient to be diagnosed with severe OSA (apnea-hypopnea index (AHI) of 30/hour or greater) and have very few symptoms that affect their quality of life where a patients with mild OSA (AHI of 5-15/hour) can be experiencing extreme symptoms.
Another aspect of the HBM is the cue to action. This essentially means that there is a cue that overrides all of the perceptions, barrier and benefits and results in the action being taken (Bedoya, 2020). In my experience, this may be a case in which a patient is scheduled for surgery and they must have a device for recovery. The patient's perceptions are overridden by the necessity of having a device in order to have the surgery. Whether or not this patient adheres to therapy afterwards, however, is a completely separate story.
In my practice, I do my best to help my patients make the most informed health decisions. When looking at how these decisions may be influenced, I believe that emphasis on education is key going forward. Helping improve patient understanding of the risks of being untreated when diagnosed with OSA will be vital in increasing the adherence of continuous positive airway pressure (CPAP) usage. With each patient in my office that is diagnosed with OSA and is coming in for CPAP therapy, I am ensuring that they are aware of the risks of being untreated. In order for the rate of adherence to improve, we must ensure that our patients are making a decision based on knowledge and understanding instead of their perceptions of a disease and it's risks.
The next component of the SEM is that of relationships. This may be family, friends, spouses, etc. (CDC, 2022). Adherence to CPAP therapy is often influenced by a patient's family. Sometimes, they are even being tested initially due to a spouse complaining of snoring and apneic breathing patterns. It is not uncommon for spouses to sleep in separate rooms due to loud snoring. In these cases, adherence to CPAP therapy often helps to improve the relationship and the relationship helps to improve adherence to therapy.
The community level of the SEM includes settings such as "schools, workplaces, and neighborhoods" (CDC, 2022). The community level has a huge influence on many of my compliant CPAP users as several workplaces require proof of compliance and adequate treatment on an annual report. The New Brunswick Department of Motor Vehicle also requires an annual report for any drivers with certain levels of licence to ensure that they are safe to have on the roads. These influences certainly have an impact on compliance and adherence to therapy.
The final level discussed by the CDC is the societal level. This level is going to affect patients differently based on their provincial funding for CPAP therapy. Patients who live in provinces that fund CPAP therapy would have one less component working against them for adherence to therapy. In New Brunswick, there is no provincial funding for sleep therapies. This means if a patient does not have private insurance to fund the device, they have to pay over $2000 out of their own pocket. Unfortunately, this is not always something that is doable for patients and often results in patients discontinuing with therapy as they cannot afford to purchase and keep up with the costs of therapy.
After looking at the different levels of influence on CPAP adherence, I think it is clear that there are many solutions that may help improve the long-term usage of many patients. First of all, education. Providing patients with all of the information necessary to make an informed decision is something that I work into my practice and will continue to do. When looking at the societal aspects, it would be fantastic for all provinces to see the benefit of CPAP treatment for those with OSA as it can help prevent or improve comorbidities and improve overall quality of life.
Resources
Baum, A., Newman, S., Weinman, J., West, R., & McManus, C. (1997). Cambridge Handbook of Psychology, Health and Medicine. The Press Syndicate of the University of Cambridge. Retrieved from https://books.google.ca/books?hl=en&lr=&id=zVh30FrAuDsC&oi=fnd&pg=PR17&dq=cambridge+handbook+of+psychology+health+and+medicine&ots=Im5RqwyIvv&sig=rmI40NhremqIXV3PeCZNb4lWnlY#v=onepage&q=cambridge%20handbook%20of%20psychology%20health%20and%20medicine&f=false
Bedoya, D. (2020, October 3). The Health Belief Model. [Video]. Youtube. https://www.youtube.com/watch?v=Knedre8Ul60
Centers for Disease Control and Prevention. (2022). The Social-Ecological Model: A Framework for Prevention. https://www.cdc.gov/violenceprevention/about/social-ecologicalmodel.html
Olsen, S., Smith, S., Oei, T., & Douglas, J. (2008). Health belief model predicts adherence to CPAP before experience with CPAP. European Respiratory Journal, 32, 710-717. https://erj.ersjournals.com/content/32/3/710
Rundo, J. V. (2019). Obstructive sleep apnea basics. Cleveland Clinic Journal of Medicine, 86, 2-9. https://doi.org/10.3949/ccjm.86.s1.02
Wolkove, N., Baltzan, M., Kamel, H., Dabrusin, R., & Palayew, M. (2008). Long-term compliance with continuous positive airway pressure in patients with obstructive sleep apnea. Canadian Respiratory Journal, 15(7), 365-369. 10.1155/2008/534372
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