Behavioural adherence in the treatments of disorders of sleep and wakefulness - a biopsychosocial approach

Crawford, Megan R. (2013) Behavioural adherence in the treatments of disorders of sleep and wakefulness - a biopsychosocial approach. PhD thesis, University of Glasgow.

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Obstructive sleep apnoea (OSA) and insomnia are the two most prevalent sleep
disorders. Their respective treatments Continuous Positive Airway Pressure
(CPAP) and Cognitive Behaviour Therapy for insomnia (CBT-I), are effective, but
at the same time challenging. It is this challenge that may translate to poor
adherence, which ultimately leads to a reduction in treatment effectiveness.
The evaluation of these treatments should not fall short of understanding
effectiveness by only considering efficacy; the effort to establish what
influences adherence makes up a large part of that goal. The aim of this thesis is
to contribute to the literature by adopting a biopsychosocial approach (BPS).
That is, the consideration of biomedical, psychological and social factors and
how they interact to influence behaviour. The implications for both CPAP and
CBT-I adherence literature were tested in the context of four experimental
Semi-structured interviews were conducted with 11 CPAP users, with 5
individuals completing the three required interviews prior to, at 1 week and 3
months after treatment initiation. The core themes emerging from a thematic
analysis were ‘internal conflict around acceptance and adherence’, ‘integration
of CPAP into life’ and ‘motivators and resources for CPAP use’. The interviews
with 11 individuals having completed a CBT-I program revealed three important
issues: ‘Making sense of CBT-I’, ‘Ongoing evaluation of components’ and
‘Obstacles to implementation’. Both studies reveal potential psychological and
social factors contributing to adherence to CPAP and CBT-I, which need to be
considered in a BPS framework.
A patient-level meta-analysis of three randomised placebo-control studies
showed that the relationship between CPAP adherence and improvements in
daytime sleepiness was caused by both physiological (high use of real CPAP
reduced sleepiness more than high use of placebo and more than low use of real
CPAP) and psychological effects (high use of placebo was superior to low use of
placebo), possibly as a result of an expectation of benefit. The results support
the importance of considering both biomedical and psychosocial factors and
their interactive effects on adherence.
The translation of the BPS approach to clinical practice will be facilitated
by the development of brief, reliable and valid measures to assess psychological
and social variables in addition to the existing biomedical tools. The Stage of
Change Scale for Insomnia (SOCSI) assessing components of the transtheoretical
model (stage of change, self-efficacy, decisional balance and processes of
change), was constructed and cognitively pre-tested in 13 individuals completing
CBT-I. The reliability and validity of this comprehensible scale was subsequently
examined in the context of a sleep restriction trial. Insomnia-related symptoms
at post-treatment and follow-up, which were significantly different from
baseline in the 27 individuals with insomnia, were associated with actigraphdetermined
adherence to the agreed bed window. The SOCSI was deemed a valid
tool with participants in the self-identified action/maintenance stage revealing
significantly better adherence, higher motivation and self-efficacy than those in
the contemplation and preparation stage. Test-retest reliability of the SOCSI was
excellent and the content analysis of open-box responses revealed information
for further validation of decisional balance and processes of change scales.
This thesis provides novel information about the variables that influence
adherence to CPAP and CBT-I. It distinguishes itself from previous efforts by
acknowledging the need for the adoption of a BPS framework. This approach is
necessary to successfully advancing not only the CPAP and CBT-I adherence
literature individually, but potentially the adherence field in general.

Item Type: Thesis (PhD)
Qualification Level: Doctoral
Keywords: Sleep apnea, insomnia, adherence, continuous positive airway pressure, cognitive behavioural therapy
Subjects: B Philosophy. Psychology. Religion > BF Psychology
R Medicine > R Medicine (General)
R Medicine > RA Public aspects of medicine > RA0421 Public health. Hygiene. Preventive Medicine
Colleges/Schools: College of Medical Veterinary and Life Sciences > Institute of Neuroscience and Psychology
Supervisor's Name: Espie, Prof. Colin and Grunstein, Prof. Ron and Bartlett, Dr. Delwyn
Date of Award: 2013
Depositing User: Dr Megan Crawford
Unique ID: glathesis:2013-4191
Copyright: Copyright of this thesis is held by the author.
Date Deposited: 18 Apr 2013 12:04
Last Modified: 21 Apr 2016 15:02

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