Studies of CPAP nonadherence have found that the most consistent indicator of continued CPAP use is perceived improvement in sleepiness (136). In some studies, CPAP adherers have been found to be more educated and have greater daytime somnolence, while nonadherers have less severe disease and concurrent medical problems (131,132). Side effects of CPAP therapy, although often cited as a primary reason for discontinuing treatment (137,138), produce only minimal adherence improvements when treated (139). Factors such as type of mask (139), titration method (auto vs. standard) (128-140), and delivery method of PAP (CPAP vs. bilevel ventilation) (141) do not reliably produce improvements in adherence or in OSA-related symptoms. Perhaps the strongest effects on predicting adherence have been demonstrated by measures of behavioral attitudes toward CPAP use. In a seminal study, Stepnowsky et al. (142) examined the predictive utility of behavioral attitudes based on psychological theories of behavior change principles. These theories have been applied to studies of behavior change for several years and have only relatively recently been employed in adherence studies. These investigators found that these self-report measures, taken only one week after the beginning of CPAP, predicted approximately 20% to 30% of the variance in one-month adherence. Predictive utility increased when the measures were taken concurrently to measuring adherence (30-40% of the variance). Aloia et al. (143) followed this study with another study that examined the efficacy of these measures over longer follow-up periods. These investigators found that these measures predicted 20% of the variance in six-month use when taken at one week and 40% of the variance when taken concurrently with measuring adherence (at three months). Together, these studies suggest that theories of behavior change principles effectively apply to the conceptualization of why individuals do or do not adhere to CPAP. Moreover, these measures can serve as gateways into discussions with patients about their attitudes toward use rather than confronting them directly with poor adherence.
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