Elsevier

Sleep Medicine

Volume 7, Issue 4, June 2006, Pages 375-379
Sleep Medicine

Brief Communication
A preliminary study of psychological factors affecting patients' acceptance of CPAP therapy for sleep apnoea syndrome

https://doi.org/10.1016/j.sleep.2005.10.005Get rights and content

Abstract

Background

Many patients abandon continuous positive airway pressure (CPAP) treatment after initial acceptance. This may be for physical or psychological reasons.

Methods

We have carried out semi-structured interviews, constructed from the Health Belief Model (HBM) with a convenience sample of patients who had recently abandoned CPAP treatment after at least 6 months of use. We explored their understanding and experiences of their OSA and of the CPAP therapy and their reasons for stopping treatment.

Results

Nine patients were interviewed (age 32–70 years; 8 males). Four patients were not clear about the nature, severity, or consequences of sleep apnoea syndrome (SAS) and did not consider themselves to be ill. Three expected to be cured by the machine. Only one patient spoke of life-threatening risk. Eight of the nine patients had other health disorders. Seven stopped CPAP because of negative experiences, including problems with the mask and noise from the machine. Two patients felt ‘liberated’ on stopping treatment.

Conclusions

Studies at the initiation stage of CPAP treatment are needed in order to identify factors impeding acceptance, which can be addressed early. The Health Belief Model, which emphasises subjective health experience and patients' beliefs about treatment, may be a useful tool for such investigations.

Introduction

The numbers of patients being diagnosed with obstructive sleep apnoea syndrome (OSAS) is rising, and continuous positive airway pressure (CPAP) therapy remains the treatment of choice [1]. Recent studies have looked at patient adherence to CPAP therapy, an important question given the tendency for patients to abandon this type of treatment [2], [3]. We have found that up to 20% of our patients refuse treatment at the initiation phase, in common with other studies [4]. Our experience is that there is then a constant rate of attrition such that 30% of accepting patients will have abandoned treatment after one year of therapy (unpublished observations from AGIRadom homecare association). These figures correspond to data from recent international studies, which indicate that rates of non-adherence to CPAP therapy range between 25–50% and that non-adherent patients typically abandon their treatment in the first few weeks of the treatment regime [5].

Poor adherence is frequently attributed to difficulties with the equipment; common reasons cited include patient discomfort with the mask, nasal dryness or congestion, as well as difficulties adapting to the pressure or the noise of the machine [3]. However, in recent years, attempts to understand patients' adherence to CPAP have widened from purely technical or physiological considerations, and it appears that psychological factors (such as emotional, cognitive or interpersonal issues) may also be predictive of adherence, as seen in other types of illness situations [6].

Psychological issues concerning patient adherence to CPAP have received limited attention to date, even though they are recognised as contributing factors in other types of treatment regimes, such as adherence to medical prescriptions or preventive health measures [7], [8]. One of the key questions addressed by health psychologists is why individuals do or do not engage in a variety of health-related behaviours [9]. Several psychological models exist which help to explain why patients adopt (or fail to adopt) certain behaviours, which protect their health (e.g. smoking cessation or exercise) or enable them to deal with illness (e.g. modifying diet or taking medication or other therapies) [9], [10]. The Health Belief Model (HBM) attempts to explain and predict patients' health behaviours by examining their attitudes and beliefs concerning their health and proposed health care interventions or therapies. This model has been developed since the 1950s [10], [11]; it originally focused on patient behaviours regarding preventive health care measures (such as the uptake of screening tests), but in recent decades it has been used as a framework for exploring patient beliefs and adherence to treatments in the contexts of acute or chronic illnesses, including, for example, hypertension [12], recurrent heart failure [13] and psychiatric disorders [14]. The HBM suggests that at least three psychological factors determine the extent to which patients adopt new health behaviours or adhere to treatment regimes to improve their well-being or manage illness [10]. These three factors include the following:

  • (a)

    the extent to which the patient considers herself or himself to be ill or vulnerable to illness;

  • (b)

    beliefs about the benefits of adopting a prescribed health behaviour or therapy;

  • (c)

    the extent to which the perceived effects of treatment outweigh the disadvantages.

Our study aimed to explore whether patients' beliefs and perceptions of their illness and treatment might explain their decision to abandon CPAP treatment.

OSAS is an example of a chronic illness whose ultimate effects can be dramatic, with increased risk of cardiovascular diseases and road traffic accidents [15], [16]. CPAP is the main form of therapy proposed for OSAS patients. CPAP treatment can improve quality of life, survival and cardiovascular risk [17], [18], [19]; nevertheless, we have observed that many patients have difficulty adapting to this form of therapy, and some decide to give it up. While some of the physical difficulties are known (such as machine-noise and uncomfortable masks), we wondered if patients' understanding and experience of the illness and the treatment with CPAP affected their decision to abandon the therapy; such psychological dimensions as described by the HBM might help to predict adherence to CPAP and thereby aid the formulation of therapeutic strategies to help patients experiencing difficulty with CPAP treatment.

We performed this preliminary study in order to explore the extent to which psychological issues may have led OSAS patients to abandon CPAP treatment and the usefulness of this model for studying adherence. We chose to study the views and experiences of a sample of OSAS patients who had been receiving CPAP therapy for several months before they finally decided to abandon the treatment. These patients would have had some time to experience CPAP therapy and the effects of treatment, unlike patients who had difficulties initially accepting CPAP and abandoned it within days or weeks.

Section snippets

Participants

Eligible patients had to have (a) been diagnosed with OSAS by polysomnography, confirming an apnoea-hypopnoea index greater than 30 per hour of sleep; and (b) received CPAP treatment for at least 6 months and had recently decided to abandon treatment. CPAP therapy had been initiated during a 2-h session with experienced paramedical personnel at the homecare agency (AGIRadom) that is part of the French Respiratory Homecare Network (Association Nationale pour le Traitement A Domicile de

Procedure

The interviews were conducted in an interview room at the AGIRadom headquarters, an environment familiar to patients treated for OSAS. Participants completed the two questionnaires and were interviewed by the trainee research psychologist (CP) who had been involved in designing the interview schedule questions. Each interview was recorded for re-transcription and lasted about 1 h. The patient responses were subsequently classified according to the HBM grill shown in Table 1.

Data about each

Participants

Of the 20 patients meeting our inclusion criteria, eight lived too far away to be interviewed. Of the 12 who were invited to participate, three refused to be interviewed, and nine patients agreed to participate in the study. Eight male and one female patient were interviewed during the 3-month study period (March–May 2004). Their ages ranged from 32 to 70 years of age (median 56 years). The number of nights equipped was between 197 and 304 (median=239 nights), with a mean observation of 4.46 h

Discussion

This preliminary study aimed to establish whether psychological issues play a role in a patient's decision to abandon CPAP therapy. Our findings are limited to nine participants who had recently abandoned CPAP treatment but indicated that their perceptions of their illness were vague and their understanding of their treatment was poor; these subjective factors may be pertinent to their decision to stop CPAP therapy.

The Health Belief Model appears to be a promising framework for exploring

References (27)

  • R. Olivier-Martin

    Facteurs psychologiques, observance et résistance aux traitements antidépresseurs

    L'Encéphale

    (1986)
  • P. Bennett

    Introduction to clinical health psychology

    (2000)
  • M. Connor et al.

    The role of social cognition in health behaviours

  • Cited by (0)

    View full text