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Original Research: Sleep Disorders |

The Efficacy of a Brief Motivational Enhancement Education Program on CPAP Adherence in OSAEducation on CPAP Adherence in OSA: A Randomized Controlled Trial FREE TO VIEW

Agnes Y. K. Lai, DN; Daniel Y. T. Fong, PhD; Jamie C. M. Lam, MD, FCCP; Terri E. Weaver, PhD; Mary S. M. Ip, MD, FCCP
Author and Funding Information

From the Department of Medicine (Drs Lai, Lam, and Ip), Queen Mary Hospital, the School of Nursing (Drs Lai and Fong), and the Research Centre of Heart, Brain, Hormone, and Healthy Aging (Dr Ip), The University of Hong Kong, Hong Kong, SAR, China; and the College of Nursing (Dr Weaver), University of Illinois at Chicago, Chicago, IL.

CORRESPONDENCE TO: Mary S. M. Ip, MD, FCCP, Queen Mary Hospital, The University of Hong Kong, 4th Floor, Professorial Block, Pokfulam, Hong Kong, SAR, China; e-mail: msmip@hku.hk


FUNDING/SUPPORT: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(3):600-610. doi:10.1378/chest.13-2228
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BACKGROUND:  Poor adherence to CPAP treatment in OSA adversely affects the effectiveness of this therapy. This randomized controlled trial (RCT) examined the efficacy of a brief motivational enhancement education program in improving adherence to CPAP treatment in subjects with OSA.

METHODS:  Subjects with newly diagnosed OSA were recruited into this RCT. The control group received usual advice on the importance of CPAP therapy and its care. The intervention group received usual care plus a brief motivational enhancement education program directed at enhancing the subjects’ knowledge, motivation, and self-efficacy to use CPAP through the use of a 25-min video, a 20-min patient-centered interview, and a 10-min telephone follow-up. Self-reported daytime sleepiness adherence-related cognitions and quality of life were assessed at 1 month and 3 months. CPAP usage data were downloaded at the completion of this 3-month study.

RESULTS:  One hundred subjects with OSA (mean ± SD, age 52 ± 10 years; Epworth Sleepiness Scales [ESS], 9 ± 5; median [interquartile range] apnea-hypopnea index, 29 [20, 53] events/h) prescribed CPAP treatment were recruited. The intervention group had better CPAP use (higher daily CPAP usage by 2 h/d [Cohen d = 1.33, P < .001], a fourfold increase in the number using CPAP for ≥ 70% of days with ≥ 4 h/d [P < .001]), and greater improvements in daytime sleepiness (ESS) by 2.2 units (P = .001) and treatment self-efficacy by 0.2 units (P = .012) compared with the control group.

CONCLUSIONS:  Subjects with OSA who received motivational enhancement education in addition to usual care were more likely to show better adherence to CPAP treatment, with greater improvements in treatment self-efficacy and daytime sleepiness.

TRIAL REGISTRY:  ClinicalTrials.gov; No.: NCT01173406; URL: www.clinicaltrials.gov

Figures in this Article

CPAP is an efficacious treatment that relieves the repetitive upper airway obstruction in OSA. CPAP adherence has been less than ideal and limits its effectiveness.1 Some studies have indicated that patient education is important in enhancing self-efficacy and, consequently, adherence to CPAP therapy.25

In the past decade, psychologic factors have been recognized as playing an important role in the determination of CPAP adherence.6,7 Social cognitive theory has been used as a conceptual model framework in identifying predictors of CPAP use8 and development of educational interventions to enhance CPAP adherence in OSA.911 Brief motivational interviewing is a patient-centered counseling style for enhancing patients’ confidence and self-management in the treatment of lifestyle problems and diseases12,13 and has been shown to be a feasible intervention in time-constrained clinical environments.14,15 Negative message framing, which emphasizes the negative consequence of untreated disease, showed a better result in improving CPAP adherence when used with patients with OSA, compared with positive message framing.16 Although the typical application of several education sessions was effective, it may not be feasible in some real-life clinical settings.911,1725 Further details regarding reported programs are listed in e-Table 1 .

In this study, we aimed to examine the efficacy of a multicomponent brief motivational enhancement education program added to usual care. It comprised an educational video, a face-to-face brief motivational interview, and a telephone follow-up call. The brief motivational enhancement education program was grounded on the components of social cognitive theory, using a brief motivational interviewing style with negative message framing. We hypothesized that subjects with OSA in the intervention group (brief motivation enhancement program plus usual care) would have better CPAP adherence and greater improvements in adherence-related cognitions and OSA-related health outcomes compared with those in the control group (usual care).

Procedure
Study Designs and Participants:

This was a randomized (1:1) controlled parallel-group clinical trial. Chinese subjects with OSA who fulfilled the inclusion and exclusion criteria were invited to participate in this study. The inclusion criteria were the following: (1) age ≥ 18 years old with newly diagnosed OSA (apnea-hypopnea index [AHI] ≥ 5), (2) receiving in-laboratory auto-CPAP titration for the first time, and (3) no prior OSA or CPAP education classes. Subjects were excluded if they had central sleep apnea, periodic leg movement disorders, coexisting COPD, pregnancy, psychiatric illness on treatment, cognitive impairment, illiteracy, unstable health conditions such as end-stage renal failure on renal replacement therapy, malignancy currently on radiotherapy or chemotherapy, or dependence in daily care or if they were unable to attend the education session before discharge from Sleep Disorders Centre after CPAP titration, had been scheduled for OSA follow-up in other hospitals, or were participating in another clinical trial.

CPAP machines were provided to the subjects in both groups during the 3-month study period. CPAP usage data were downloaded at the completion of the study. All outcomes were assessed at three time points: baseline, which was after signing the consent but before randomization and performing titration; 1 month; and 3 months. The research protocol was approved by the Institutional Review Board of The University of Hong Kong/Hospital Authority Hong Kong West Cluster with HKW IRB reference number: UW177 and was registered at the National Institutes of Health (identifier number: NCT01173406).

Interventions
Usual Care:

Usual care was provided by nurses in the Sleep Disorders Center who provided a 15-min talk to introduce the basic operation of the CPAP device and titration procedure. Subjects tried the CPAP device for approximately 30 min for acclimatization before the start of the overnight titration procedure. The next morning after CPAP titration, the subject met the medical officer-in-charge, who provided an explanation of OSA, explained the subject’s particular test results, and prescribed treatment. Nurses gave further advice (about 15 min) on the importance of CPAP therapy and care of accessories before the subjects were given their devices and discharged from the Sleep Disorder Center. Additional information on this procedure is provided in e-Appendix 1.

Brief Motivational Enhancement Education:

The aim of brief motivational enhancement education is to enhance those factors that may influence behavioral skills and bring about behavioral change. The World Health Organization has stated that information, motivation, and behavioral skills are essential components for behavioral change.26,27 Risk perception of a health threat is the subjective judgment of that threat based on the person’s knowledge. It creates the precondition for a change, and it has been shown to be related to treatment compliance.28 Poor awareness of illness, especially in chronic diseases, has been shown to be related to noncompliance to treatment.28 Outcome expectancy is the individual’s perception of the likely consequences of a behavior, whereas self-efficacy refers to the belief in one’s own ability to learn and perform behaviors toward a desired outcome.29 Our brief motivational enhancement education program, which was designed to enhance the subject’s perception of the risk of OSA, confidence in the ability to apply CPAP treatment (self-efficacy), and association of their behavior to the desired outcome (adherence) or outcome expectancy, included a session in the morning after CPAP titration and a telephone call on day 2 of CPAP use, providing early follow-up.30Figure 1 shows the conceptual framework and time of conduction of the education program.

Figure Jump LinkFigure 1  The conceptual framework and time of conduction of the motivational enhancement education program.Grahic Jump Location

The subject was shown a 25-min video together with an information booklet providing the knowledge on OSA and CPAP. The video included the real-life experience of a current CPAP user. Then, a 20-min patient-centered face-to-face brief motivational interview was conducted and aimed to facilitate the subject’s intrinsic motivation toward CPAP therapy. Several tools and strategies were applied, which were as follows: (1) using importance and confidence rulers with higher-lower exercise to explore the barriers and facilitators of using CPAP (e-Appendix 1), (2) using a decision matrix to discuss the positive and negative aspects of using or not using CPAP, and (3) looking forward to the expected outcomes or benefits of using CPAP. The interview was conducted by one of the investigators (A. Y. K. L.), who was both a nurse and polysomnographic technologist who had received prior training to conduct motivational interviews by a clinical psychologist (member of Motivational Interviewing Network of Trainers). The sequential steps of the brief motivation interview are described in e-Appendix 1. Thereafter, a 10-min phone call was made to the subjects by the same interviewer (A. Y. K. L.) on day 2 of CPAP use. Checklists for interview and phone follow-up were used to ensure treatment fidelity. The concrete communication strategies are illustrated in Figure 2.

Figure Jump LinkFigure 2  Content of usual care and brief motivational education for control and intervention groups.Grahic Jump Location
Outcomes

The predefined primary outcome was the interventional effect on daily usage of CPAP and the consistency of the effect over time. The secondary outcomes were proportion of adherent users, intention to use CPAP, daytime sleepiness, adherence-related cognitions, and health-related quality of life.

Adherence to CPAP:

The primary outcome indicator for CPAP adherence was the mean daily usage: the total number of hours of CPAP mask on divided by the total number of study days, which was downloaded with software. The secondary outcome indicators for CPAP adherence were as follows: (1) proportion of adherent users: the proportion of subjects who used CPAP for ≥ 4 h/d for at least 70% of study days2022,31; (2) intention to use: the percentage of days on which CPAP has been switched on (ie, total number of switch-on days divided by the total number of study days)23; and (3) usage index: the percentage of days using CPAP for at least 4 h/d (ie, total number of such CPAP days divided by the total number of study days).2

Adherence-Related Cognitions and Daytime Sleepiness:

The Self-efficacy Measure for Sleep Apnea was used to assess adherence-related cognitions.32,33 Epworth Sleepiness Scale (ESS) was used to assess the likelihood of falling asleep in eight different situations.34

Health-Related Quality of Life:

The Functional Outcomes of Sleep Questionnaire,35 Calgary Sleep Apnea Quality of Life Index,3638 and Short Form-36 Health Survey Questionnaire3942 were used to measure the impact of sleep apnea on several aspects of quality of life. Additional information is provided in e-Appendix 1.

Sample Size, Randomization, and Concealment

The sample size calculation was based on primary comparison of CPAP adherence between the intervention group and the control group and was grounded on the information from previous studies of education on CPAP adherence in subjects with OSA.10,17,43 Assuming a small attrition rate, 50 subjects per group were estimated for this randomized controlled trial (RCT). Randomization sequence was created using a computer-generated randomization program (www.randomization.com). The randomization was stratified into three severity groups: AHI ≥ 5 to < 15, AHI ≥ 15 to < 30, and AHI > 30, and with 1:1 allocation using a block size of 6. Additional information is provided in e-Appendix 1.

Statistical Analysis

The predefined primary outcome was the interventional effect on daily usage of CPAP and the consistency of the interventional effect over time. The interventional effects on CPAP adherence, symptom of daytime sleepiness, health-related quality of life, and adherence-related cognitions were examined by linear mixed-effects model, and interventional effect on proportion of adherent users was examined by generalized estimating equations. The methods took into account the extra covariance between repeated measurements taken at baseline, 1 month, and 3 months, and the potential confounding factors as covariates. Further details of the statistical analysis can be reviewed in e-Appendix 1.

Patient Recruitment

Figure 3 shows the subjects’ disposition. A total of 212 subjects with OSA referred for CPAP titration were screened during the study period. One hundred six subjects did not meet the inclusion criteria, and six subjects refused to participate. Thus, 100 subjects were recruited. They were randomized to either control group (usual care) (n = 51) or intervention group (brief motivational enhancement education plus usual care) (n = 49). There were two dropouts. One subject in the control group who withdrew after 2 days of CPAP use left the study because of intolerance to CPAP. The other subject in the intervention group withdrew because he underwent uvulopalatopharyngoplasty surgery after using CPAP for 1 month. There was no significant difference between two groups at baseline, although only marginal insignificances were noted for the history of hypertension/cardiovascular and treatment self-efficacy. There was no significant difference in the number of family members attending the education class or the subjects’ contact (phone calls and clinical visits) and in the nature of referral source between the two groups (Table 1).

Figure Jump LinkFigure 3  The subjects’ disposition.Grahic Jump Location
Table Graphic Jump Location
TABLE 1  ] Baseline Characteristics of the Two Groups

Data are presented as mean ± SD, median (interquartile range) or No. (%). Intervention group received motivational enhancement education and usual care; control group received usual care only. Independent t test or χ2 test were performed. SEMSA = self-efficacy measures of sleep apnea.

a 

Referral source was categorized into self-referred, partner-referred, and doctor-referred, according to the response to the question, “Who prompted you to seek help for OSA?”

CPAP Adherence

The interventional effect of the motivational enhancement education group over the usual care group was consistent during the study period (time by group, P = .113). Compared with the control group, the subjects in the intervention group had a greater mean daily CPAP usage by 2.0 h/d (4.4 ± 1.8 h/d vs 2.4 ± 2.3 h/d; 95% CI, 1.3-2.8 h/d; P < .001) with a large effect size, 1.33, with adjustment for potential confounders of the history of hypertension/cardiovascular disease and treatment self-efficacy at baseline. In addition, such differences between the intervention group and the control group still persisted when the other definitions of adherence were applied. They were as follows: proportion of CPAP-adherent users (OR, 4.3; 95% CI, 2.0-9.0; P < .001), intention to use CPAP (difference, 31%; 95% CI, 20%-42%; P < .001), and usage index (difference, 31%; 95% CI, 19%-43%; P < .001) (Table 2).

Table Graphic Jump Location
TABLE 2  ] CPAP Adherence Across Time for Both Groups

Data are presented as mean ± SD unless otherwise noted. Intervention group received motivational enhancement education and usual care; control group received usual care only.

a 

Mean daily usage = the number of hours CPAP with mask on divided by the total number of study days.

b 

Linear mixed-effects models were performed, with adjusting for history of hypertension/cardiovascular diseases and treatment self-efficacy at baseline.

c 

Within-group comparisons: the comparison among 1 wk, 1 mo, and 3 mo, P < .05.

d 

Within-group comparisons: the difference between 1 wk and 3 mo, P < .05.

e 

Within-group comparisons: the difference between 1 wk and 1 mo, P < .05.

f 

Proportion of adherent subjects = the proportion of subjects who used CPAP for ≥ 4 h/d for at least 70% of study days.

g 

Generalized estimating equation analyses were performed, with adjusting for history of hypertension/cardiovascular diseases and treatment self-efficacy at baseline.

h 

Usage index = the percentage of days using CPAP for at least 4 h/d (ie, total number of such CPAP days divided by the total number of study days).

i 

Intention to use = the percentage of days on which CPAP machine has been switched (ie, total number of switch-on days on divided by the total number of study days).

In the control group, compared with 1 week, the CPAP adherence decreased at 1 month (P < .05) and also at 3 months (P < .05) in all measures. In the intervention group, the CPAP adherence did not change between 1 week and 1 month (P > .05) but decreased at 3 months (P < .05) (Table 2).

Adherence-Related Cognitions

The interventional effect (change from baseline) on risk perception in the two groups at the two time epochs did not differ (time by group, P = .076). There was no significant difference in the changes on risk perception between the two groups over the study period (P = .564).

The interventional effect (change from baseline) on outcome expectancies (time by group, P = .022) and treatment self-efficacy (time by group, P = .024) in the two groups differed at the two time epochs. For changes in outcome expectations, there was no significant difference between the two groups, both at 1 month (P = .373) and 3 months (P = .162). For changes in treatment self-efficacy, no significant difference was seen between the two groups at 1 month (P = .704), whereas the motivational enhancement education group significantly improved in treatment self-efficacy score by 0.2 units (95% CI, 0.0-0.4; P = .012) compared with the control group at 3 months (Fig 4).

Figure Jump LinkFigure 4  Adherence-related cognition scores across time for both groups. A, Risk perception. B, Outcome expectancies. C, Treatment self-efficacy.Grahic Jump Location

There were positive relationships between CPAP adherence and treatment self-efficacy and outcome expectancies at 1 month and 3 months. However, there was no association between CPAP usage and risk perceptions during the study period (Table 3).

Table Graphic Jump Location
TABLE 3  ] The Association Between CPAP Adherence, Adherence-Related Cognitions, and Improvement of Daytime Sleepiness
a 

The change in Epworth Sleepiness Scale score from specific time point to baseline.

Sleepiness and Quality of Life

During the 3-month study period, the subjects in the intervention group significantly reduced ESS score by 2.2 units (95% CI, 0.9-3.5; P = .001; time by group, P = .912) when compared with the control group (Fig 5). In addition, there were positive relationships between CPAP adherence and improvement in daytime sleepiness at 1 month and at 3 months (Table 3).

Figure Jump LinkFigure 5   Epworth Sleepiness Scale scores across time for both groups.Grahic Jump Location

However, the changes from baseline in the intervention group and the control group did not significantly differ in health-related quality-of-life outcomes at the two time epochs. No significant improvement in any score of the three health-related quality-of-life scales was found in the intervention group, compared with the control group (e-Table 2).

This is the first RCT, to our knowledge, demonstrating that a brief motivational enhancement education program, using one session and one phone follow-up call, was able to enhance adherence to CPAP treatment with a large effect size (Cohen d = 1.33). These results were consistent from 1 week to 3 months of CPAP use. The intervention group had a higher daily CPAP usage by 2 h/d, fourfold the number of adherent CPAP users, and greater improvements in treatment self-efficacy and daytime sleepiness, compared with the control group.

The motivational enhancement education program was designed to target psychocognitive factors (risk perception, outcome expectation, and treatment self-efficacy) identified in the social cognitive theory,44,45 aiming to enhance subjects’ knowledge, motivation, and self-efficacy in using CPAP. Researchers suggested that knowledge is a prerequisite for changing behavior,26,27,45,46 and a well-designed program with educational video could enhance the adherence for CPAP therapy.47 In the video, a current CPAP user shared his real-life experience to act as a reference for naive CPAP users.10 One study giving video education only showed no effect on CPAP adherence, but the group that had viewed the education video had a higher attendance rate at follow-up visits,48 suggesting that it may be a contributing factor toward the retention of the subjects on CPAP treatment. The individual motivational interview aimed to enhance motivation, empower treatment self-efficacy, and set realistic expectations, and the telephone call acted as an early follow-up to boost the attempts of using CPAP.30

To our knowledge, the current educational program is the simplest one among reported education programs to enhance adherence to CPAP use in sleep apnea (e-Table 1 ). Our program focused on the initial phase of CPAP treatment and was delivered at a convenient and timely schedule. Similar to the findings of most other studies on CPAP education,21,43,4951 we achieved a significant improvement in daytime sleepiness but not in scores in quality of life. Only a few studies showed significant improvements in quality-of-life measurements in the intervention group over the control group.21,43 It may relate to the insufficient statistical power to detect these small effect sizes. The sample size of this study was based on previous studies on CPAP adherence but not on quality of life. Daytime sleepiness is one of the most noticeable complaints in subjects with OSA, and any improvement in sleepiness would be more easily appreciated by the subjects. The positive relationships between improvement in sleepiness and CPAP adherence may be partly due to the positive reinforcement between the two factors.

Regarding adherence-related cognitions, there was a significant improvement in treatment self-efficacy in the intervention group compared with the control group. This finding is coherent with previous reports.10,28 The improvement in treatment self-efficacy may be explained by knowledge enhancement10 and empowerment of self-efficacy through the interview. The level of self-efficacy influences the effort to a target behavior and affects one’s ability to persist in the task in face of obstacles29; such improvement in treatment self-efficacy could also explain better CPAP adherence.20,51 However, there was no significant improvement in risk perception and outcome expectancies in the intervention group compared with the control group. It may be explained by the difficulty in its further enhancement of the high risk perception score (2.7 ± 0.5 at baseline) in this study relative to the one from the work of Deng et al20 (2.3 ± 0.4 at baseline), which had shown positive results in the enhancement of risk perception, and the insufficient statistical power to detect the small effect size in outcome expectancies. In addition, there were positive associations between CPAP adherence and treatment self-efficacy and outcome expectation on CPAP therapy after 3-month CPAP use. Outcome expectancies and perceived risk beliefs may play influential roles in adopting and maintaining the new health behavior.29,52,53 According to Bandura’s54 self-efficacy theory, there is a causal influence of the outcome expectancies on the judgment of how well the subjects could perform the activities.55,56 Researchers suggested that treatment self-efficacy and outcome expectancies measured after CPAP treatment may relate to a patient’s decision to use CPAP.7,12,5759 Hence, although we only identified significant improvement in treatment self-efficacy in the intervention group compared with the control group, we cannot exclude a mediating contribution of risk perception and outcome expectancies in enhancing CPAP use.

The average CPAP usage in the current study was not so high, relative to the other CPAP educational programs (e-Table 1). It may be explained by the difference between the study samples. Most previous studies focused on subjects with higher severity of OSA and greater degree of daytime sleepiness. This study included subjects with mild to severe OSA and a wide range of daytime sleepiness (ESS, 0-22). Some subjects had low ESS score; CPAP was indicated as adjunctive therapy due to comorbid diseases, such as hypertension. The subjects had a median AHI of 29. One-half of them had only mild to moderate OSA (AHI < 30), and 61% of them had no excessive daytime sleepiness (ESS < 10). Despite this, our education program demonstrated good usefulness in enhancing CPAP use, making it an applicable tool in real clinical setting.

There were several limitations in this study. First, although the subjects and the data collectors were not told of the assigned treatment groups, double-blinding is difficult to achieve in behavioral educational studies such as this. Second, we did not have the chance to invite the significant others or bed partners of all subjects to join this study. Third, this was not a time-matched study, and the duration of health-care workers with the subjects was approximately 30 min (20-min interview plus 10-min phone call) longer in the intervention group than in the control group. It is important to note that the effectiveness of such a program may be influenced by the communication skills of the interviewer. Thus, as in our study, in which the interviewer had received training to deliver this program, the relevant health professionals should receive focused training to deliver the motivational interviewing as applied in the context of CPAP therapy.

The duration of the study was 3 months, and the impact of this intervention over usual care in a longer duration is not clear. The sample has restricted eligibility criteria, and the sample size may not be enough to detect small effect size on other health outcomes. Different health-care environments may necessitate adaptations of the intervention program. Before this intervention can be transitioned to clinical practice, further validation of the efficacy findings reported and replication of the study for effectiveness in the typical clinic population would be warranted. Larger and longer studies are needed to determine the persistence of effects on CPAP adherence and related impact on health outcomes and the cost-benefit issue relating to such a patient education program.

In conclusion, we demonstrated that this nonconfrontational patient-centered tailored education intervention has high efficacy in improving CPAP adherence with better alleviation of daytime sleepiness in OSA. Diagnosis and treatment prescriptions are futile if patients ultimately do not comply with the treatment, and CPAP therapy is a treatment that is more demanding on the patient’s cooperation than just taking a pill. Evidence from RCTs is the first step toward the rational development of sound clinical practice and the cost-effective use of health-care resources.

Author contributions: A. Y. K. L. had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. A. Y. K. L., D. Y. T. F., J. C. M. L., and M. S. M. I. contributed to the study concept and design; A. Y. K. L. contributed to the acquisition and analysis of data; A. Y. K. L., D. Y. T. F., J. C. M. L., T. E. W., and M. S. M. I. contributed to the interpretation of data; A. Y. K. L. contributed to drafting of the manuscript; A. Y. K. L., D. Y. T. F., J. C. M. L., T. E. W., and M. S. M. I. contributed to critical revision of the manuscript for important intellectual content; and J. C. M. L. and M. S. M. I. contributed administrative support.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Lai has been sponsored to attend Sleep and Breathing Conference 2013 and 18th Congress of the Asian Pacific Society of Respirology by ResMed and Koninklijke Philips N.V., respectively. Dr Lam has been sponsored to attend Worldsleep Conference 2011, World Congress of Sleep Apnea 2012, and Sleep and Breathing Conference 2013 by ResMed, Koninklijke Philips N.V., and Homecare Medical Ltd, respectively. Dr Weaver is the member of the board of directors of ViMedicus, Inc. She has received research support from Teva Pharmaceuticals Industries, Ltd and has received equipment for her research from Koninklijke Philips N.V. She has been a consultant for Apnex Medical, Inc, and has received royalty fees for use of the Functional Outcomes of Sleep Questionnaire from NovaSom, Apnex Medical, Inc, GlaxoSmithKline, Koninklijke Philips N.V., Cephalon, Inc (now Teva Pharmaceuticals Industries, Ltd), and Nova Nordisk. Dr Ip has received honoraria from Koninklijke Philips N.V. for a lecture in Worldsleep 2011 and a lecture at Kyoto University in 2011. Dr Fong has reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: We thank Dace Svikis, PhD, for her teaching in motivational interviewing and her expert opinion; Jack Lam, RPSGT, for technical support in producing the education video, randomization, and allocation concealment procedures; Michelle Cheong, RPSGT, for technical support in CPAP mask fitting and machine issuing; and Kaiser Sung, BSc, Kelvin Lau, BSc, Eppie Sin, BN, Po-Yee Chu, BN, and the staff of Ho Ting Shek Sleep Disorders Centre, Queen Mary Hospital for data collection.

Additional information: The e-Appendix and e-Tables can be found in the Supplemental Materials section of the online article.

AHI

apnea-hypopnea index

ESS

Epworth Sleepiness Scale

RCT

randomized controlled trial

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Smith CE, Dauz ER, Clements F, Werkowitch M, Whitman R. Patient education combined in a music and habit-forming intervention for adherence to continuous positive airway (CPAP) prescribed for sleep apnea. Patient Educ Couns. 2009;74(2):184-190. [CrossRef] [PubMed]
 
Deng T, Wang Y, Sun M, Chen B. Stage-matched intervention for adherence to CPAP in patients with obstructive sleep apnea: a randomized controlled trial. Sleep Breath. 2013;17(2):791-801. [CrossRef] [PubMed]
 
Olsen S, Smith SS, Oei TPS, Douglas J. Motivational interviewing (MINT) improves continuous positive airway pressure (CPAP) acceptance and adherence: a randomized controlled trial. J Consult Clin Psychol. 2012;80(1):151-163. [CrossRef] [PubMed]
 
Wang W, He G, Wang M, Liu L, Tang H. Effects of patient education and progressive muscle relaxation alone or combined on adherence to continuous positive airway pressure treatment in obstructive sleep apnea patients. Sleep Breath. 2012;16(4):1049-1057. [CrossRef] [PubMed]
 
Damjanovic D, Fluck A, Bremer H, Müller-Quernheim J, Idzko M, Sorichter S. Compliance in sleep apnoea therapy: influence of home care support and pressure mode. Eur Respir J. 2009;33(4):804-811. [CrossRef] [PubMed]
 
Fox N, Hirsch-Allen AJ, Goodfellow E, et al. The impact of a telemedicine monitoring system on positive airway pressure adherence in patients with obstructive sleep apnea: a randomized controlled trial. Sleep. 2012;35(4):477-481. [PubMed]
 
Sparrow D, Aloia MS, DeMolles DA, Gottlieb DJ. A telemedicine intervention to improve adherence to continuous positive airway pressure: a randomised controlled trial. Thorax. 2010;65(12):1061-1066. [CrossRef] [PubMed]
 
Fisher JD, Fisher WA. Changing AIDS-risk behavior. Psychol Bull. 1992;111(3):455-474. [CrossRef] [PubMed]
 
Fisher JD, Fisher WA, Misovich SJ, Kimble DL, Malloy TE. Changing AIDS risk behavior: effects of an intervention emphasizing AIDS risk reduction information, motivation, and behavioral skills in a college student population. Health Psychol. 1996;15(2):114-123. [CrossRef] [PubMed]
 
Schumann C, Lenz G, Berghöfer A, Müller-Oerlinghausen B. Non-adherence with long-term prophylaxis: a 6-year naturalistic follow-up study of affectively ill patients. Psychiatry Res. 1999;89(3):247-257. [CrossRef] [PubMed]
 
Schwarzer R, Fuchs R. Self-efficacy and health behaviours.. In:Conner M, Norman P., eds. Predicting Health Behaviour: Research and Practice With Social Cognition Models. Buckingham, England: Open University Press; 1995.
 
Weaver TE, Chasens ER. Continuous positive airway pressure treatment for sleep apnea in older adults. Sleep Med Rev. 2007;11(2):99-111. [CrossRef] [PubMed]
 
Kribbs NB, Pack AI, Kline LR, et al. Effects of one night without nasal CPAP treatment on sleep and sleepiness in patients with obstructive sleep apnea. Am Rev Respir Dis. 1993;147(5):1162-1168. [CrossRef] [PubMed]
 
Weaver TE, Maislin G, Dinges DF, et al. 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):727-732. [PubMed]
 
Lai AYK, Fong DYT, Lam JCM, Weaver TE, Ip MS. Linguistic and psychometric validation of the Chinese version of the self-efficacy measures for sleep apnea questionnaire. Sleep Med. 2013;14(11):1192-1198. [CrossRef] [PubMed]
 
Johns MW. Reliability and factor analysis of the Epworth Sleepiness Scale. Sleep. 1992;15(4):376-381. [PubMed]
 
Weaver TE, Laizner AM, Evans LK, et al. An instrument to measure functional status outcomes for disorders of excessive sleepiness. Sleep. 1997;20(10):835-843. [PubMed]
 
Flemons WW, Reimer MA. Development of a disease-specific health-related quality of life questionnaire for sleep apnea. Am J Respir Crit Care Med. 1998;158(2):494-503. [CrossRef] [PubMed]
 
Flemons WW, Reimer MA. Measurement properties of the Calgary Sleep Apnea Quality of Life Index. Am J Respir Crit Care Med. 2002;165(2):159-164. [CrossRef] [PubMed]
 
Mok WYW, Lam CLK, Lam B, Cheung MT, Yam L, Ip MS. A Chinese version of the Sleep Apnea Quality of Life Index was evaluated for reliability, validity, and responsiveness. J Clin Epidemiol. 2004;57(5):470-478. [CrossRef] [PubMed]
 
Ware JEJ Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30(6):473-483. [CrossRef] [PubMed]
 
McHorney CA, Ware JEJ Jr, Raczek AE. The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Med Care. 1993;31(3):247-263. [CrossRef] [PubMed]
 
McHorney CA, Ware JEJ Jr, Lu JF, Sherbourne CD. The MOS 36-item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups. Med Care. 1994;32(1):40-66. [CrossRef] [PubMed]
 
Lam CL, Gandek B, Ren XS, Chan MS. Tests of scaling assumptions and construct validity of the Chinese (HK) version of the SF-36 Health Survey. J Clin Epidemiol. 1998;51(11):1139-1147. [CrossRef] [PubMed]
 
Hui DSC, Chan JKW, Choy DKL, et al. Effects of augmented continuous positive airway pressure education and support on compliance and outcome in a Chinese population. Chest. 2000;117(5):1410-1416. [CrossRef] [PubMed]
 
Luszczynska A, Schwarzer R. Predicting Health Behavior: Research and Practice With Social Cognition Models. New York, NY: Open University Press; 2005.
 
Bandura A. Health promotion by social cognitive means. Health Educ Behav. 2004;31(2):143-164. [CrossRef] [PubMed]
 
Mazzuca SA. Does patient education in chronic disease have therapeutic value? J Chronic Dis. 1982;35(7):521-529. [CrossRef] [PubMed]
 
Sin DD, Mayers I, Man GCW, Pawluk L. Long-term compliance rates to continuous positive airway pressure in obstructive sleep apnea: a population-based study. Chest. 2002;121(2):430-435. [CrossRef] [PubMed]
 
Jean Wiese H, Boethel C, Phillips B, Wilson JF, Peters J, Viggiano T. CPAP compliance: video education may help! Sleep Med. 2005;6(2):171-174. [CrossRef] [PubMed]
 
Wang Y, Gao W, Sun M, Chen B. Adherence to CPAP in patients with obstructive sleep apnea in a Chinese population. Respir Care. 2012;57(2):238-243. [PubMed]
 
Basoglu OK, Midilli M, Midilli R, Bilgen C. Adherence to continuous positive airway pressure therapy in obstructive sleep apnea syndrome: effect of visual education. Sleep Breath. 2012;16(4):1193-1200. [CrossRef] [PubMed]
 
Stepnowsky CJ, Palau JJ, Gifford AL, Ancoli-Israel S. A self-management approach to improving continuous positive airway pressure adherence and outcomes. Behav Sleep Med. 2007;5(2):131-146. [CrossRef] [PubMed]
 
Rimal RN. Perceived risk and self-efficacy as motivators: understanding individuals’ long-term use of health information. J Commun. 2001;51(4):633-654. [CrossRef]
 
Janz NK, Becker MH. The health belief model: a decade later. Health Educ Q. 1984;11(1):1-47. [CrossRef] [PubMed]
 
Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84(2):191-215. [CrossRef] [PubMed]
 
Kuusisto K, Knuuttila V, Saarnio P. Pre-treatment expectations in clients: impact on retention and effectiveness in outpatient substance abuse treatment. Behav Cogn Psychother. 2011;39(3):257-271. [CrossRef] [PubMed]
 
Williams DM, Anderson ES, Winett RA. A review of the outcome expectancy construct in physical activity research. Ann Behav Med. 2005;29(1):70-79. [CrossRef] [PubMed]
 
Stepnowsky CJ, Marler MR, Palau JJ, Annette Brooks J. Social-cognitive correlates of CPAP adherence in experienced users. Sleep Med. 2006;7(4):350-356. [CrossRef] [PubMed]
 
Olsen S, Smith S, Oei TPS, Douglas J. Health belief model predicts adherence to CPAP before experience with CPAP. Eur Respir J. 2008;32(3):710-717. [CrossRef] [PubMed]
 
Ye L, Liang ZA, Weaver TE. Predictors of health-related quality of life in patients with obstructive sleep apnoea. J Adv Nurs. 2008;63(1):54-63. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1  The conceptual framework and time of conduction of the motivational enhancement education program.Grahic Jump Location
Figure Jump LinkFigure 2  Content of usual care and brief motivational education for control and intervention groups.Grahic Jump Location
Figure Jump LinkFigure 3  The subjects’ disposition.Grahic Jump Location
Figure Jump LinkFigure 4  Adherence-related cognition scores across time for both groups. A, Risk perception. B, Outcome expectancies. C, Treatment self-efficacy.Grahic Jump Location
Figure Jump LinkFigure 5   Epworth Sleepiness Scale scores across time for both groups.Grahic Jump Location

Tables

Table Graphic Jump Location
TABLE 1  ] Baseline Characteristics of the Two Groups

Data are presented as mean ± SD, median (interquartile range) or No. (%). Intervention group received motivational enhancement education and usual care; control group received usual care only. Independent t test or χ2 test were performed. SEMSA = self-efficacy measures of sleep apnea.

a 

Referral source was categorized into self-referred, partner-referred, and doctor-referred, according to the response to the question, “Who prompted you to seek help for OSA?”

Table Graphic Jump Location
TABLE 2  ] CPAP Adherence Across Time for Both Groups

Data are presented as mean ± SD unless otherwise noted. Intervention group received motivational enhancement education and usual care; control group received usual care only.

a 

Mean daily usage = the number of hours CPAP with mask on divided by the total number of study days.

b 

Linear mixed-effects models were performed, with adjusting for history of hypertension/cardiovascular diseases and treatment self-efficacy at baseline.

c 

Within-group comparisons: the comparison among 1 wk, 1 mo, and 3 mo, P < .05.

d 

Within-group comparisons: the difference between 1 wk and 3 mo, P < .05.

e 

Within-group comparisons: the difference between 1 wk and 1 mo, P < .05.

f 

Proportion of adherent subjects = the proportion of subjects who used CPAP for ≥ 4 h/d for at least 70% of study days.

g 

Generalized estimating equation analyses were performed, with adjusting for history of hypertension/cardiovascular diseases and treatment self-efficacy at baseline.

h 

Usage index = the percentage of days using CPAP for at least 4 h/d (ie, total number of such CPAP days divided by the total number of study days).

i 

Intention to use = the percentage of days on which CPAP machine has been switched (ie, total number of switch-on days on divided by the total number of study days).

Table Graphic Jump Location
TABLE 3  ] The Association Between CPAP Adherence, Adherence-Related Cognitions, and Improvement of Daytime Sleepiness
a 

The change in Epworth Sleepiness Scale score from specific time point to baseline.

References

Engleman HM, Wild MR. Improving CPAP use by patients with the sleep apnoea/hypopnoea syndrome (SAHS). Sleep Med Rev. 2003;7(1):81-99. [CrossRef] [PubMed]
 
Budhiraja R, Parthasarathy S, Drake CL, et al. Early CPAP use identifies subsequent adherence to CPAP therapy. Sleep. 2007;30(3):320-324. [PubMed]
 
Smith I, Nadig V, Lasserson TJ. Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines for adults with obstructive sleep apnoea. Cochrane Database Syst Rev. 2009;;(2):CD007736.
 
La Piana GE, Scartabellati A, Chiesa L, et al. Long-term adherence to CPAP treatment in patients with obstructive sleep apnea: importance of educational program. Patient Prefer Adherence. 2011;5:555-562. [CrossRef] [PubMed]
 
Wickwire EM, Lettieri CJ, Cairns AA, Collop NA. Maximizing positive airway pressure adherence in adults: a common-sense approach. Chest. 2013;144(2):680-693. [CrossRef] [PubMed]
 
Zozula R, Rosen R. Compliance with continuous positive airway pressure therapy: assessing and improving treatment outcomes. Curr Opin Pulm Med. 2001;7(6):391-398. [CrossRef] [PubMed]
 
Sawyer AM, Canamucio A, Moriarty H, Weaver TE, Richards KC, Kuna ST. Do cognitive perceptions influence CPAP use? Patient Educ Couns. 2011;85(1):85-91. [CrossRef] [PubMed]
 
Wickwire EM. Behavioral management of sleep-disordered breathing. Prim Psychiatry. 2009;16(2):34-41.
 
Aloia MS, Smith K, Arnedt JT, et al. Brief behavioral therapies reduce early positive airway pressure discontinuation rates in sleep apnea syndrome: preliminary findings. Behav Sleep Med. 2007;5(2):89-104. [CrossRef] [PubMed]
 
Richards D, Bartlett DJ, Wong K, Malouff J, Grunstein RR. Increased adherence to CPAP with a group cognitive behavioral treatment intervention: a randomized trial. Sleep. 2007;30(5):635-640. [PubMed]
 
Aloia MS, Di Dio L, Ilniczky N, Perlis ML, Greenblatt DW, Giles DE. Improving compliance with nasal CPAP and vigilance in older adults with OAHS. Sleep Breath. 2001;5(1):13-21. [CrossRef] [PubMed]
 
Aloia MS, Arnedt JT, Stepnowsky CJ, Hecht J, Borrelli B. Predicting treatment adherence in obstructive sleep apnea using principles of behavior change. J Clin Sleep Med. 2005;1(4):346-353. [PubMed]
 
Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change.2nd ed. New York: Guilford Press; 2002.
 
Colby SM, Monti PM, Barnett NP, et al. Brief motivational interviewing in a hospital setting for adolescent smoking: a preliminary study. J Consult Clin Psychol. 1998;66(3):574-578. [CrossRef] [PubMed]
 
Rollnick S, Heather N, Bell A. Negotiating behaviour change in medical settings: the development of brief motivational interviewing. J Ment Health. 1992;1(1):25-37. [CrossRef]
 
Trupp RJ, Corwin EJ, Ahijevych KL, Nygren T. The impact of educational message framing on adherence to continuous positive airway pressure therapy. Behav Sleep Med. 2011;9(1):38-52. [CrossRef] [PubMed]
 
Hoy CJ, Vennelle M, Kingshott RN, Engleman HM, Douglas NJ. Can intensive support improve continuous positive airway pressure use in patients with the sleep apnea/hypopnea syndrome? Am J Respir Crit Care Med. 1999;159(4 pt 1):1096-1100. [CrossRef] [PubMed]
 
Smith CE, Dauz ER, Clements F, Puno FN, Cook D, Doolittle G, et al. Telehealth services to improve nonadherence: a placebo-controlled study. Telemed J E Health. 2006;12(3):289-296. [CrossRef] [PubMed]
 
Smith CE, Dauz ER, Clements F, Werkowitch M, Whitman R. Patient education combined in a music and habit-forming intervention for adherence to continuous positive airway (CPAP) prescribed for sleep apnea. Patient Educ Couns. 2009;74(2):184-190. [CrossRef] [PubMed]
 
Deng T, Wang Y, Sun M, Chen B. Stage-matched intervention for adherence to CPAP in patients with obstructive sleep apnea: a randomized controlled trial. Sleep Breath. 2013;17(2):791-801. [CrossRef] [PubMed]
 
Olsen S, Smith SS, Oei TPS, Douglas J. Motivational interviewing (MINT) improves continuous positive airway pressure (CPAP) acceptance and adherence: a randomized controlled trial. J Consult Clin Psychol. 2012;80(1):151-163. [CrossRef] [PubMed]
 
Wang W, He G, Wang M, Liu L, Tang H. Effects of patient education and progressive muscle relaxation alone or combined on adherence to continuous positive airway pressure treatment in obstructive sleep apnea patients. Sleep Breath. 2012;16(4):1049-1057. [CrossRef] [PubMed]
 
Damjanovic D, Fluck A, Bremer H, Müller-Quernheim J, Idzko M, Sorichter S. Compliance in sleep apnoea therapy: influence of home care support and pressure mode. Eur Respir J. 2009;33(4):804-811. [CrossRef] [PubMed]
 
Fox N, Hirsch-Allen AJ, Goodfellow E, et al. The impact of a telemedicine monitoring system on positive airway pressure adherence in patients with obstructive sleep apnea: a randomized controlled trial. Sleep. 2012;35(4):477-481. [PubMed]
 
Sparrow D, Aloia MS, DeMolles DA, Gottlieb DJ. A telemedicine intervention to improve adherence to continuous positive airway pressure: a randomised controlled trial. Thorax. 2010;65(12):1061-1066. [CrossRef] [PubMed]
 
Fisher JD, Fisher WA. Changing AIDS-risk behavior. Psychol Bull. 1992;111(3):455-474. [CrossRef] [PubMed]
 
Fisher JD, Fisher WA, Misovich SJ, Kimble DL, Malloy TE. Changing AIDS risk behavior: effects of an intervention emphasizing AIDS risk reduction information, motivation, and behavioral skills in a college student population. Health Psychol. 1996;15(2):114-123. [CrossRef] [PubMed]
 
Schumann C, Lenz G, Berghöfer A, Müller-Oerlinghausen B. Non-adherence with long-term prophylaxis: a 6-year naturalistic follow-up study of affectively ill patients. Psychiatry Res. 1999;89(3):247-257. [CrossRef] [PubMed]
 
Schwarzer R, Fuchs R. Self-efficacy and health behaviours.. In:Conner M, Norman P., eds. Predicting Health Behaviour: Research and Practice With Social Cognition Models. Buckingham, England: Open University Press; 1995.
 
Weaver TE, Chasens ER. Continuous positive airway pressure treatment for sleep apnea in older adults. Sleep Med Rev. 2007;11(2):99-111. [CrossRef] [PubMed]
 
Kribbs NB, Pack AI, Kline LR, et al. Effects of one night without nasal CPAP treatment on sleep and sleepiness in patients with obstructive sleep apnea. Am Rev Respir Dis. 1993;147(5):1162-1168. [CrossRef] [PubMed]
 
Weaver TE, Maislin G, Dinges DF, et al. 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):727-732. [PubMed]
 
Lai AYK, Fong DYT, Lam JCM, Weaver TE, Ip MS. Linguistic and psychometric validation of the Chinese version of the self-efficacy measures for sleep apnea questionnaire. Sleep Med. 2013;14(11):1192-1198. [CrossRef] [PubMed]
 
Johns MW. Reliability and factor analysis of the Epworth Sleepiness Scale. Sleep. 1992;15(4):376-381. [PubMed]
 
Weaver TE, Laizner AM, Evans LK, et al. An instrument to measure functional status outcomes for disorders of excessive sleepiness. Sleep. 1997;20(10):835-843. [PubMed]
 
Flemons WW, Reimer MA. Development of a disease-specific health-related quality of life questionnaire for sleep apnea. Am J Respir Crit Care Med. 1998;158(2):494-503. [CrossRef] [PubMed]
 
Flemons WW, Reimer MA. Measurement properties of the Calgary Sleep Apnea Quality of Life Index. Am J Respir Crit Care Med. 2002;165(2):159-164. [CrossRef] [PubMed]
 
Mok WYW, Lam CLK, Lam B, Cheung MT, Yam L, Ip MS. A Chinese version of the Sleep Apnea Quality of Life Index was evaluated for reliability, validity, and responsiveness. J Clin Epidemiol. 2004;57(5):470-478. [CrossRef] [PubMed]
 
Ware JEJ Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30(6):473-483. [CrossRef] [PubMed]
 
McHorney CA, Ware JEJ Jr, Raczek AE. The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Med Care. 1993;31(3):247-263. [CrossRef] [PubMed]
 
McHorney CA, Ware JEJ Jr, Lu JF, Sherbourne CD. The MOS 36-item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups. Med Care. 1994;32(1):40-66. [CrossRef] [PubMed]
 
Lam CL, Gandek B, Ren XS, Chan MS. Tests of scaling assumptions and construct validity of the Chinese (HK) version of the SF-36 Health Survey. J Clin Epidemiol. 1998;51(11):1139-1147. [CrossRef] [PubMed]
 
Hui DSC, Chan JKW, Choy DKL, et al. Effects of augmented continuous positive airway pressure education and support on compliance and outcome in a Chinese population. Chest. 2000;117(5):1410-1416. [CrossRef] [PubMed]
 
Luszczynska A, Schwarzer R. Predicting Health Behavior: Research and Practice With Social Cognition Models. New York, NY: Open University Press; 2005.
 
Bandura A. Health promotion by social cognitive means. Health Educ Behav. 2004;31(2):143-164. [CrossRef] [PubMed]
 
Mazzuca SA. Does patient education in chronic disease have therapeutic value? J Chronic Dis. 1982;35(7):521-529. [CrossRef] [PubMed]
 
Sin DD, Mayers I, Man GCW, Pawluk L. Long-term compliance rates to continuous positive airway pressure in obstructive sleep apnea: a population-based study. Chest. 2002;121(2):430-435. [CrossRef] [PubMed]
 
Jean Wiese H, Boethel C, Phillips B, Wilson JF, Peters J, Viggiano T. CPAP compliance: video education may help! Sleep Med. 2005;6(2):171-174. [CrossRef] [PubMed]
 
Wang Y, Gao W, Sun M, Chen B. Adherence to CPAP in patients with obstructive sleep apnea in a Chinese population. Respir Care. 2012;57(2):238-243. [PubMed]
 
Basoglu OK, Midilli M, Midilli R, Bilgen C. Adherence to continuous positive airway pressure therapy in obstructive sleep apnea syndrome: effect of visual education. Sleep Breath. 2012;16(4):1193-1200. [CrossRef] [PubMed]
 
Stepnowsky CJ, Palau JJ, Gifford AL, Ancoli-Israel S. A self-management approach to improving continuous positive airway pressure adherence and outcomes. Behav Sleep Med. 2007;5(2):131-146. [CrossRef] [PubMed]
 
Rimal RN. Perceived risk and self-efficacy as motivators: understanding individuals’ long-term use of health information. J Commun. 2001;51(4):633-654. [CrossRef]
 
Janz NK, Becker MH. The health belief model: a decade later. Health Educ Q. 1984;11(1):1-47. [CrossRef] [PubMed]
 
Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84(2):191-215. [CrossRef] [PubMed]
 
Kuusisto K, Knuuttila V, Saarnio P. Pre-treatment expectations in clients: impact on retention and effectiveness in outpatient substance abuse treatment. Behav Cogn Psychother. 2011;39(3):257-271. [CrossRef] [PubMed]
 
Williams DM, Anderson ES, Winett RA. A review of the outcome expectancy construct in physical activity research. Ann Behav Med. 2005;29(1):70-79. [CrossRef] [PubMed]
 
Stepnowsky CJ, Marler MR, Palau JJ, Annette Brooks J. Social-cognitive correlates of CPAP adherence in experienced users. Sleep Med. 2006;7(4):350-356. [CrossRef] [PubMed]
 
Olsen S, Smith S, Oei TPS, Douglas J. Health belief model predicts adherence to CPAP before experience with CPAP. Eur Respir J. 2008;32(3):710-717. [CrossRef] [PubMed]
 
Ye L, Liang ZA, Weaver TE. Predictors of health-related quality of life in patients with obstructive sleep apnoea. J Adv Nurs. 2008;63(1):54-63. [CrossRef] [PubMed]
 
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