Original ArticlePutative facilitators and barriers for adherence to CPAP treatment in patients with obstructive sleep apnea syndrome: A qualitative content analysis
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.
Section snippets
Design, context and participants
By permission of the Regional Ethics Committee for Human Research, Linköping University, Sweden a descriptive explorative design with qualitative content analysis (QCA) was used [19]. This explorative inductive approach aims to understand, analyse, and describe patients’ in-depth descriptions of different situations and processes based on data most often collected through semi-structured interviews [20]. QCA can be used for descriptions of the manifest content (i.e., surface and visible content
Results
The patients’ experiences of adherence to CPAP treatment were described by two themes: “Putative facilitators for adherence to CPAP treatment” (Table 2 in online supplementary material) and “Putative barriers for adherence to CPAP treatment” (Table 3 in online supplementary material).
Discussion
We identified a great variety of factors that could be seen as putative facilitators (Table 2; online supplementary material) and barriers for adherence to CPAP treatment (Table 3; online supplementary material). To the best of our knowledge, no other study has described the holistic in-depth perspective of the patient in relation to adherence to CPAP treatment.
Previous research has demonstrated that practical problems and side-effects of CPAP treatment are prevalent [7], [17]. The side-effects
Acknowledgements
The authors wish to thank the Health Research Council in the South-East of Sweden for financial support, Grant FORSS-12568 and FORSS-12710. We wish to thank Gerd Pihl from the Department of Clinical Neurophysiology, Linköping University Hospital, as well as Jan Albers and Anna Ståhlkrantz from the Department of Internal Medicine, County Hospital Ryhov, Jönköping, Sweden, for their contributions to the study.
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