Putative facilitators and barriers for adherence to CPAP treatment in patients with obstructive sleep apnea syndrome: A qualitative content analysis

Abstract

Introduction

Effective treatment of obstructive sleep apnea syndrome (OSAS) with continuous positive airway pressure (CPAP) can reduce morbidity and mortality, but adherence rates are low without a clear consensus of causes.

Objective

To explore the experiences of adherence to CPAP treatment in patients with OSAS.

Methods

A qualitative content analysis was employed. Data were collected by in-depth interviews with 23 purposively selected patients.

Results

Adherence to CPAP treatment was summarized according to “facilitators” and “barriers” to CPAP treatment. Facilitators for adherence, as described by the patients were a desire to avoid symptoms, knowledge about the risk for medical consequences, fear of negative social consequences and disturbing the sleep of significant others. Other facilitators were a positive attitude to CPAP treatment, trust in healthcare personnel, a sense of engagement from the spouse and a feeling of physical improvement. Barriers included experiencing practical problems, negative psychological effects of the equipment, and negative attitudes to the treatment. Other barriers were side-effects as well as insufficient support from healthcare personnel and the spouse.

Conclusion

Adherence to CPAP treatment is a multifaceted problem including patient, treatment, condition, social and healthcare related factors. Knowledge about facilitators and barriers for adherence to CPAP treatment can be used in interventional strategies.

Introduction

Obstructive sleep apnea (OSA) is a common sleep-related breathing disorder where repeated episodic collapses of the upper airways during sleep cause apneas and/or hypopneas [1], [2]. The resulting sleep fragmentation can cause daytime symptoms, including sleepiness, headaches and cognitive dysfunction. This condition is termed obstructive sleep apnea syndrome (OSAS) [3]. Apart from the short-term negative consequences caused by disturbed breathing, a growing body of evidence indicates that OSAS is also a risk factor for hypertension, cardiac failure, stroke [4], and occupational accidents due to sleepiness. The treatment of choice is continuous positive airway pressure (CPAP) [5]. Adherence to CPAP treatment is important since sufficient use can eliminate apneas completely and improve sleep quality, excessive daytime sleepiness (EDS), and quality of life (QOL) [6]. Furthermore, it can reduce morbidity and mortality in cardiovascular diseases as well as consumption of health care resources [7]. The adherence rates to CPAP, however, are low without a clear consensus of causes [8], [9].

The World Health Organisation defines adherence as the “extent to which a person’s behaviour—taking medications, following a diet, and/or executing lifestyle changes—corresponds with agreed recommendations from a health care provider” [10]. The term has come to replace the term compliance, as the use of adherence more explicitly emphasizes the patient as an autonomously acting individual. As the exact amount of CPAP usage necessary to obtain positive health effects is debated [7], it is difficult to operationalise adherence to CPAP use in a way that is universally agreed upon. While it has been common to define adherence as using CPAP for at least 4 h per night [11], there seems to be a dose–response relationship between CPAP usage and reductions in severity indices [12].

Adherence to CPAP treatment has been described as a significant problem, despite the fact that the treatment improves the life situation for patients with OSAS in many different ways [5], [7], [9], [13]. Several studies have reported relatively low CPAP adherence, with reported usage ranging from 65% to 80% and an initial refusal to engage in treatment of 8–15% (8). In a study by Kribbs [11] only 46% of patients were considered adherent when the 4 h per night rule was applied. Explanations of low and varying degrees of adherence have predominantly focused on technical and physiological aspects [7], [9]. Side-effects from treatment, such as dry throat, nasal congestion and mask leaks tend to be common [14], [15] and are believed to reduce adherence [16]. Several technical solutions have been proposed to overcome these problems, such as air humidifiers and different types of devices, yet the increase in adherence has not been proportional to the reduction in side-effects offered by these solutions [17]. Objective measures of disease severity are only weakly to moderately associated with CPAP adherence [7]. Studies where specific adherence models have been applied to CPAP-treated patients have shown unsatisfactory results. These difficulties to explain low CPAP adherence rates have led to calls for more research on the influence of psychological factors on CPAP adherence [8], [17], [18].

The difficulties to identify relevant factors for CPAP adherence can, at least partially, be attributed to a paucity of studies investigating factors that are important from the patient’s perspective. It is possible that specific factors might influence the patient’s decision to use CPAP and that these specific factors differ from the factors that influence a patient’s decision to take a drug, for example. In-depth descriptions of patients’ experiences of adherence to CPAP treatment can be very important in gaining a better understanding of important aspects of CPAP adherence and in identifying factors associated with treatment adherence that have been neglected in previous research. Accordingly, the aim of this study was to explore the in-depth experiences associated with adherence to CPAP treatment in patients with OSAS.