Psychological Barriers Associated with CPAP Adaptation

Suboptimal adherence to therapy is a generalized, longstand- ing problem within the medical industry, and CPAP is no exception. Over the past decade many articles have been directed at determining factors responsible for poor CPAP compliance. Past studies have tended to focus upon easily measured characteristics of the patient’s therapy and reported symptoms. As a result clinicians are well versed in addressing issues such as mask discomfort, pressure intolerance and nasal symptoms.

There are also studies that stress the importance of patient education and device instruction. These studies point to the promise of behavioral interventions as an approach aimed at improving CPAP use. The majority of these studies highlight the importance of problem solving within the early days of therapy1,2, typically accomplished through physician-patient rapport and education provided by the CPAP provider (HME).

Clinicians apply many methods of intervention and education to support the patient which, unfortunately, even when addressed may not result in a compliant patient.

So What else could be Affecting Compliance?
Through information gathering during the initial set up of the CPAP we learn characteristics of our patients. We observe personality traits, comprehension, apprehension and coping skills. We might even make a mental note that the patient will do well on therapy or be one of the challenging patients to work with. It should perhaps, then, come as no surprise that emerging research is starting to support the idea that psycho- logical factors may play an important role in determining acceptance of, and adherence to, CPAP3 One such factor is that patients develop their own beliefs and expectations about OSA and CPAP even before they try it4. Therefore the impor- tance of ensuring patients have a positive perception towards CPAP therapy, should not be under-estimated.

Another potentially overlooked consideration is the aesthetics of the device. There is an interesting line of medical literature that can be found in the area of Industrial Design that suggests how the patient’s perception of the device may affect adherence. The literature emphasizes the need to move away from a purely functional approach to product usability, and focus more on human-product interaction. It is reported that a pleasurable user experience is critical in the process that leads to adherence with medical recommendations.

‘Product Pleasure’ is defined by Designer Patrick Jordan as “The emotional, hedonic, and practical benefits associated with a product”6. Hedonic relates to the perception of beauty, or aesthetic design qualities which enhance satisfaction. The bottom line of this theory is that a positive effect in regard to aesthetics shall lead to increased product use.

Howard Leventhal’s Dual Process Model
According to this model there are two contexts which affect whether a patient will be adherent or non-adherent. Leventhal presents these as emotional and cognitive contexts. Initially the emotional context is more powerful than the cognitive component in affecting adherence. However cognitive factors last longer.

Emotional Context
Emotional context is most often related to patient-doctor rapport. However in the field of OSA and CPAP devices, this is also relevant to:

• Aesthetic qualities (ugly vs. beautiful) 
• Sounds (buzzer vs. chime)
• Tonal qualities (authoritative vs. empathetic)
• Grammatical structure (command vs request)

Cognitive Context
Cognitive context refers to objective information, or how thepatients’ experience is linked to their interaction with the device.

• Device familiarity (recognizable features, clock, alarm, controls)
• Ease of use
• Relating to the device as it fits into the home environment
• Device communication that compliance goals arebeing met

In CPAP therapy this model makes sense because it is the first exposure to the device and the time when a patient connects emotionally to the prod- uct. They may say to themselves, “This doesn’t look so intimidating,” and they make a decision whether to try it (or not). Additionally, once they get home on their own and begin interacting with the device, the cognitive context kicks in. It stands to reason that the easier the device is to use and the more the device holds familiarity and fits into the patient’s home environment the better the adaptation may be.

Levanthal’s model parallels Patrick Jordan’s theory that emotions play an important role in medical device acceptance. Ideally the cognitive and emotion- al context would be balanced to result in a positive effect on the patient.

In this way, initial feelings of positivity toward a medical device help insti- gate initial acceptance and the likelihood of long-term therapy success is en- hanced when these positive feelings are complimented with other behavioral and educational interventions.

Compliance with CPAP, the gold standard treatment for OSA, remains poor despite considerable and sustained effort. It’s time to take a look at other avenues to enhance and encourage CPAP users (existing and future) to use their device every night, all night. Proactively addressing patient perceptions relating to their health, the treatment they are embarking on and the device they are now com- mitted to might just provide the best new opportunity to tackle this problem.

Robin Randolph is a Marketing and Business Development professional with over 20 years of experience in the Sleep Industry; considered a national ”sleep ex- pert” by industry leaders. Robin is employed by Fisher & Paykel Healthcare in the capacity of Marketing Manager for North America. Robin’s creative process and strategic thinking has led to both the creation and launching of a number of pro- grams and products in the healthcare industry with an emphasis on Sleep medicine.


1. Budhiraja, R., et al., Early CPAP use identifies subsequent adherence to CPAP therapy. Sleep, 2007. 30(3): p. 320–324.

2. Pepin, J.L., et al., Effective compliance during the first 3 months of continuous positive airway pressure: A European prospective study of 121 patients. American Journal of Respiratory and Critical Care Medicine, 1999. 160(4): p. 1124–1129.

3. Wild, M.R., et al., Can psychological factors help us to determine adherence to CPAP? A prospective study. European Respiratory Journal, 2004. 24(3): p. 461–465.

4. Olsen, S., et al., Health belief model predicts adherence to CPAP before experience with CPAP. European Respiratory Journal, 2008. 32(3): p. 710–717.

5. Goyd M, Daniel, Positive User Experience and Medical Adherence DPPI’03. Jun 23–26, 2003 Pittsburgh, PA. Abstract

6. Patrick Jordan, Patricks as presented by Danial Goyd M. Positive User Experience and Medical Adherence DPPI’03. Jun 23–26, 2003 Pittsburgh, PA. Abstract

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