By Amber Carmen Arroyo, PhD
Continuous positive airway pressure (CPAP) therapy is the first line and is typically considered the gold standard treatment for obstructive sleep apnea (OSA).1 Yet, adherence to CPAP has been consistently low since CPAP’s inception, generally ranging from just 30 to 60%.2 Despite exponential growth in the rate of OSA diagnoses,3 a recent review found that despite technological advancements, rates of adherence have remained unchanged over the past two decades.1 So why are rates of adherence to CPAP therapy so low, and how can we improve people’s behaviors around CPAP? Well, an entire field is dedicated to answering questions like these.
Behavioral science is the study of human behavior and the factors that influence it. In the context of health behaviors, it seeks to understand why people make certain choices related to their well-being and how those choices can be modified to achieve healthier outcomes. For OSA specifically, behavioral science can be used to understand why people do or do not use their CPAP and how to change their psychological decision-making to lead to more regular CPAP use. This article examines the key theories of behavioral science, their core constructs, and how they can be implemented in the field of sleep medicine to improve CPAP adherence among sleep apnea patients.
Foundations of Behavioral Science
There are more than eighty theories of behavioral science that provide insight into the process of altering behaviors. Each theory offers its own perspective on what drives behavior change. For example, social cognitive theory4 posits that self-efficacy, outcome expectancies, intentions, perceived barriers, and goals are the most important psychological factors influencing whether a person will perform a health behavior, such as using their CPAP machine. The Health Belief Model5 suggests that perceived susceptibility, severity, benefits, barriers, cues to action, and self-efficacy are the foremost drivers of health behavior change.
What unites all these theories is the presence of psychological factors that initiate change in health behaviors. Regardless of what the specific psychological factors are, all theories assert that an individual’s psychology serves as key leverage point for initiating and sustaining health behavior changes like increased CPAP use. Identifying the psychological factors that influence a patient’s decision to use their CPAP machine consistently is pivotal for lasting habit formation and sleep apnea symptom management.
By identifying and modifying these psychological factors that predict decision-making around regular CPAP use, healthcare professionals can empower patients to successfully treat their sleep apnea and improve their health and well-being. In recent years, there has been a greater scientific movement to measure psychological constructs when evaluating CPAP adherence. This is because there is a growing body of evidence demonstrating that targeting psychosocial factors in CPAP promotion can be effective in increasing adherence.6 If we understand which psychological aspects influence regular CPAP use, we can manipulate these triggers to enact lasting CPAP use.
Psychological Drivers of CPAP Adherence
All behaviors, including health behaviors like CPAP use, initiate with a psychological decision. Patient non-adherence to CPAP therapy can thus be explained by a deficit in one or more of the psychological factors of CPAP decision-making. As discussed in the previous section, there are many different theories of behavior change, all claiming to pinpoint the key drivers of behavior. This variability likely arises from these theories each tapping into fundamental truths about human behavior, and their ability to reliably forecast behavior changes hinges on an interplay of factors, including patient characteristics, the specific behaviors targeted, and the circumstances at hand.
Thus, while certain psychological constructs consistently emerge as the most prevalent predictors of CPAP adherence, it is crucial to acknowledge that this may not be universally applicable to all individuals or may not remain static for a single patient throughout their treatment journey. As is standard practice in patient care, it is important to use evidence-based decision-making to inform treatment strategies and to monitor and alter the course of treatment as needed. What works for one patient may not work for another, and what is effective now may become ineffective over time. The starting point for the patient journey should be where the weight of the evidence lies for the largest body of patients, and then branch out from this foundation as needed.
Research identifies a handful of psychological factors predictive of CPAP adherence for patients. Several psychological factors have been identified as important, and the best approach is likely multifactorial and requires targeting multiple psychological predictors of CPAP adherence.
One influential study found differences between CPAP adherent and non-adherent patients in terms of their psychological risk perceptions, symptom recognition, self-efficacy, outcome expectations, treatment goals, and treatment facilitators/barriers.7 Other studies have identified psychological factors predicting CPAP adherence as cognitive/motivational knowledge,8 beliefs about OSA and CPAP, 9 social support,10 health value,11 perceived barriers12, and decisional balance.13
Several studies conducted over decades have identified self-efficacy, risk perception, and outcome expectancies as critical determinants of CPAP use.6 While this is not meant to be a comprehensive list of the psychological factors linked to CPAP adherence, it does highlight some of the pervasive psychological predictors deemed significant in CPAP decision-making. It also underscores the key differences in psychology between patients who adhere to CPAP therapy and those who do not.
A patient’s lack of adherence to CPAP therapy does not signify a lost cause. Rather, it provides an opportunity to address the underlying psychological barriers or deficits that may influence their poor adherence to CPAP.
Evidence-Based Strategies for Behavior Change
The most effective way to bring about lasting change in health behavior is by modifying the underlying psychological factors predictive of that health behavior. In the context of CPAP adherence, this means altering the psychological factors that trigger an individual’s decision to use the CPAP machine consistently. We can accomplish this by using evidence-based behavior change techniques (BCTs). BCTs are the irreducible active ingredients of interventions used to facilitate behavior change, and there are 93 BCTs listed in the most common taxonomy of BCTs.14
Extensive work has been dedicated to pinpointing which BCTs demonstrate a significant connection to specific psychological constructs. The Human Behaviour Change Project15 brought together a panel of global experts in behavior change. They systematically reviewed an extensive collection of research articles on behavior change interventions, resulting in the creation of a database that establishes connections between each of the BCTs and the psychological factors they influence to ultimately drive behavior change.
The complete database is available on their website to explore which psychological factors are significantly linked to specific BCTs. The project’s website also provides access to a range of tools and training materials to be utilized freely. In addition, there are useful training materials related to understanding and implementing BCTs on the Center for Behavior Change16 website (bct-taxonomy.com).
To give an example, the psychological construct self-efficacy (an individual’s belief about their capability to successfully perform a behavior) is present in several theories of behavior change. The BCTs linked to changes in self-efficacy are:
- Instructions on how to perform the behavior,
- Demonstration of behavior,
- Behavioral practice/rehearsal,
- Graded tasks,
- Verbal persuasion about capability,
- Focus on past success,
As an illustration of one BCT link to self-efficacy, we can take the BCT ‘problem-solving.’ A sleep technologist could guide a patient in troubleshooting common CPAP equipment issues, such as mask leak or discomfort. Being guided through the process of successfully solving a common barrier to CPAP use could increase levels of self-efficacy within the patient and result in increased CPAP use.
Technologists and physicians in the sleep field naturally employ various techniques, yet sometimes without a deliberate determination about why specific approaches are chosen. Given the limited time available for patient interaction during office visits, it becomes critical to utilize these moments judiciously, drawing from the full spectrum of evidence-based practices at one’s disposal. Indeed, interventions informed by theories of behavior change have consistently demonstrated greater efficacy compared to those lacking such theoretical foundations,17 and it has been noted that the integration of techniques from health behavior theories can enhance effectiveness of sleep interventions.18
Enhancing CPAP Adherence in Patient Care
While a technologist or physician in a sleep clinic may not have a background in behavioral science, there are still ways of implementing techniques from behavioral science in everyday practice. One way is to assess the psychological constructs a patient may have deficits in, either formally through self-report surveys or through normal conversation that takes place during the patient visit.
One prominent self-report survey is the Self-Efficacy Measure for Sleep Apnea (SEMSA-26),19 used to measure a patient’s psychological risk perceptions of sleep apnea, their outcome expectancies of CPAP therapy, and their treatment self-efficacy. The article by Weaver and colleagues19 provides the full survey and how to calculate scores for each of the three psychological constructs it measures. When self-report surveys are not feasible, another approach is to pay attention to patient’s attitudes and statements during office visits. For example, while describing how to use CPAP and the importance of wearing it each night, a patient states, “I’m not sure if I can do this every night. It seems too complicated,” this is an indication that their self-efficacy is low.
When a deficit is noticed in one of the psychological constructs associated with poor CPAP adherence, the technician or physician can use the BCTs known to increase those constructs to ultimately drive better adherence to CPAP therapy. Below are some cases of how this could be implemented.
Case 1: Enhancing Social Support. We know that more social support is associated with greater CPAP adherence.10 If you observe that a patient lacks social support, you can employ one of the BCTs associated with enhancing social support. For example, encourage the patient to join a local or online support group for individuals with sleep apnea. Another strategy is to incorporate family members or bed partners in the CPAP education process to create a supportive environment.
Case 2: Increasing Perceived Risk. We know that patients with lower risk perceptions of sleep apnea are more likely to be non-adherent to CPAP therapy.7 We know from the database that the BCT ‘information about health consequences’ is significantly linked to increases in perceived risk. In cases where a patient appears indifferent or lacks understanding about the risks associated with sleep apnea, one can apply this BCT by educating the patient on the potential long-term health risks associated with untreated sleep apnea and how CPAP usage can mitigate that risk. Another effective BCT linked to perceived risk is ‘salience of consequences’ (emphasizing consequences to make them more memorable), which can be implemented through visual aids like infographics to visually represent the physiological impact of untreated sleep apnea.
Case 3: Improving Self-Efficacy. We know that self-efficacy is one of the strongest predictors of CPAP adherence.6 If a patient is struggling to use the CPAP machine for an entire night and feels overwhelmed by the prospect of using it for a full night, the BCT ‘graded tasks’ can be employed to bolster their self-efficacy. Recommending a gradual approach, starting with shorter durations of CPAP use, like during a nap or for a few hours initially, and then progressively extending the duration as smaller milestones are achieved. This step-by-step approach can help the patient build confidence to be successful with CPAP therapy. Another effective BCT ‘self-talk’ is valuable when a patient is experiencing self-doubt or negative self-talk related to their ability to use their CPAP machine. This presents an opportunity to encourage the patient to engage in positive self-talk and affirmations such as “I am capable of using my CPAP machine consistently” and “I am taking control of my sleep apnea and improving my health.” These affirmations can serve as powerful countermeasures against negative thoughts to promote a healthier mindset toward using the CPAP machine consistently.
This article gave a brief introduction to behavioral science, yet its scope extends far beyond the theories and techniques discussed here. It encompasses a complex interplay of factors, including the cognitive, social, and environmental determinants of health. All sleep medicine professionals are encouraged to explore the online courses, webinars, and certifications available through the Society of Behavioral Sleep Medicine. The annual conference offers valuable research insights and training opportunities applicable to all professionals in the field of sleep medicine.
Unfortunately, the current healthcare system often lacks the capacity for extensive one-on-one time with patients, and some patients simply require extra support to be successful with CPAP treatment. As a response, an increasing number of sleep medicine providers are turning to remote patient monitoring reimbursement to extend support beyond regular office visits.
Sleep apnea continues to be a prominent concern for public health, and rates of diagnosis are only increasing. The unwavering low levels of CPAP adherence that have persisted for two decades can no longer be tolerated. The onus cannot solely be on patients to improve CPAP adherence, and there are individuals who want to treat their sleep apnea but just need extra support to be successful. Sleep medicine professionals have a trove of techniques and a robust evidence base from behavioral science to draw upon in order to assist patients in achieving success with CPAP treatment.
Amber Carmen Arroyo, PhD, is an expert in health psychology and has published research in peer-reviewed journals on integrating behavioral science with technology to improve sleep health and well-being.
- Rotenberg BW, Murariu D, Pang KP. Trends in CPAP adherence over twenty years of data collection: a flattened curve. Journal of Otolaryngology-Head & Neck Surgery. 2016;45:1-9.
- Weaver TE, Sawyer AM. Adherence to continuous positive airway pressure treatment for obstructive sleep apnea: implications for future interventions. Indian J Med Res. 2010;131:245–58.
- Peppard PE, Hagen EW. The last 25 years of obstructive sleep apnea epidemiology—and the next 25?. Am J Resp Crit Care. 2018;197(3):310-2.
- Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Prentice-Hall, Inc. 1986.
- Janz NK, Becker MH. The health belief model: A decade later. Health Educ Q. 1984;11(1):1-47.
- Sawyer AM, Gooneratne NS, Marcus CL, Ofer D, Richards KC, Weaver TE. A systematic review of CPAP adherence across age groups: clinical and empiric insights for developing CPAP adherence interventions. Sleep Med Rev. 2011;15(6):343-56.
- Sawyer AM, Deatrick JA, Kuna ST, Weaver TE. Differences in perceptions of the diagnosis and treatment of obstructive sleep apnea and continuous positive airway pressure therapy among adherers and nonadherers. Qual Health Res. 2010;20(7):873-92.
- Likar LL, Panciera TM, Erickson AD, Rounds S. Group education sessions and compliance with nasal CPAP therapy. Chest. 1997;111:1273e7.
- Poulet C, Veale D, Arnol N, Levy P, Pepin JL, Tyrrell J. Psychological variables as predictors of adherence to treatment by continuous positive airway pressure. Sleep Med. 2009;10:993e9.
- Russo-Magno P, O’Brien A, Panciera T, Rounds S. Compliance with CPAP therapy in older men with obstructive sleep apnea. J Am Geriatr Soc. 2001;49(9):1205–11.
- Wild MR, Engleman HM, Douglas NJ, Espie CA. Can psychological factors help us to determine adherence to CPAP? A prospective study. Eur Respir J. 2004;24:461e5.
- Sage CE, Southcott AM, Brown SL. The health belief model and compliance with CPAP treatment for obstructive sleep apnea. Behav Change. 2001;18: 177e85.
- Stepnowsky CJ, Marler MR, Ancoli-Israel S. Determinants of nasal CPAP compliance. Sleep Med. 2002;3:239e47
- Michie S, Richardson M, Johnston M., Abraham C, Francis J, Hardeman W, Eccles MP, Cane J, Wood CE. The Behavior Change Technique Taxonomy (v1) of 93 hierarchically clustered techniques: Building an international consensus for the reporting of behavior change interventions. Ann Behav Med. 2013;46(1):81-95.
- Human Behaviour-Change Project. Human Behaviour-Change Project (HBCP): Advancing and Applying the Science of Behaviour Change through Machine Learning. Accessed September 26, 2023. https://www.humanbehaviourchange.org/.
- UCL Centre for Behaviour Change. UCL BCT Taxonomy—Home. 2014. https://www.bct-taxonomy.com/
- Glanz K, Bishop DB. The role of behavioral science theory in development and implementation of public health interventions. Annu Rev Public Health. 2010;31:399-418.
- Mead MP, Irish LA. Application of health behaviour theory to sleep health improvement. J Sleep Res. 2020;29(5):e12950.
- Weaver TE, Maislin G, Dinges DF, Younger J, Cantor C, McCloskey S, Pack AI. Self-efficacy in sleep apnea: Instrument development and patient perceptions of obstructive sleep apnea risk, treatment benefit, and volition to use continuous positive airway pressure. Sleep. 2003;26(6):727-32.