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Title: Behavioural adherence in the treatments of disorders of sleep and wakefulness : a biopsychosocial approach
Author: Crawford, Megan R.
ISNI:       0000 0004 2735 0537
Awarding Body: University of Glasgow
Current Institution: University of Glasgow
Date of Award: 2013
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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 studies. 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 iii 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.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available
Keywords: BF Psychology ; R Medicine (General) ; RA0421 Public health. Hygiene. Preventive Medicine