Discrimination Predicts Suboptimal Adherence to CPAP Treatment and Mediates Black-White Differences in Use

Abstract

Background

Although racial and ethnic differences in CPAP adherence for OSA are widely established, no studies have examined the influence of perceived racial discrimination on CPAP usage, to our knowledge.

Research Question

(1) Do Black adults with OSA report experiencing greater amounts of discrimination than non-Hispanic White adults? (2) Is discrimination associated with poorer CPAP adherence over time, independent of self-identified race? (3) Does discrimination mediate the relationship between self-identified Black race and CPAP usage?

Study Design and Methods

In this prospective study, Black and non-Hispanic White adults with OSA initiating CPAP were enrolled from two sleep centers and completed questionnaires including sociodemographics, perceived discrimination, daytime sleepiness, insomnia symptoms, and depressive symptoms. Perceived discrimination was measured using the Everyday Discrimination Scale (EDS). Black and White group comparisons for baseline sociodemographic variables, sleep symptoms, and perceived discrimination were performed with Student t test or χ²/Fisher exact test, as appropriate. A linear regression model was completed with self-identified Black race and EDS total score as the primary independent variables of interest and mean daily CPAP usage at 30 and 90 days serving as the dependent outcomes. This regression modeling was repeated after adjusting for psychosocial variables known to be associated with CPAP usage. EDS total score was explored as a potential mediator of the association between self-identified Black race and mean daily CPAP adherence at 30 and 90 days.

Results

The sample for this analysis consisted of 78 participants (31% female, 38% Black) with a mean age of 57 ± 14 years. Sixty percent of the Black adults reported they experienced racial discrimination at least a few times each year. Relative to White adults, Black adults were also more likely to indicate more than one reason for discrimination (27% vs 4%, P = .003). Adjusting for discrimination, self-identified Black race was associated with 1.4 (95% CI, −2.3 to −0.4 h; P = .006) and 1.6 (95% CI, −2.6 to −0.6 h; P = .003) fewer hours of mean daily CPAP usage at 30 and 90 days, respectively. In the fully adjusted model, a 1-unit change in the total discrimination score (more discrimination) was associated with a 0.08-h (95% CI, 0.01-0.15 h; P = .029) and 0.08-h (95% CI, 0.01-0.16 h; P = .045) change in mean daily CPAP usage at 30 and 90 days, respectively.

Interpretation

Adults with OSA who encountered racial discrimination experienced greater decrement in CPAP usage than those who did not experience racial discrimination.

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Take-home Points.

Study Questions: (1) Do Black adults with OSA report experiencing greater amounts of discrimination than non-Hispanic White adults? (2) Is discrimination associated with poorer CPAP adherence over time, above and beyond self-identified race? (3) Does discrimination mediate the relationship between self-identified Black race and CPAP usage?

Results: The sample consisted of 78 participants (31% female, 38% Black) with a mean age of 57 ± 14 years. Sixty percent of Black adults reported that they experienced racial discrimination at least a few times a year. Relative to White adults, Black participants were also more likely to report more than one reason for experiencing discrimination (27% vs 4%; P = .003). Adjusting for discrimination, self-identified Black race was associated with 1.4 (95% CI, −2.3 to −0.4 h; P = .006) and 1.6 (95% CI, −2.6 to −0.6 h; P = .003) fewer hours of mean daily CPAP usage at 30 and 90 days, respectively. In the fully adjusted model, a 1-unit change in the total discrimination score (more discrimination) was associated with 0.08-h (95% CI, 0.01-0.15 h; P = .029) and 0.08-h (95% CI, 0.01-0.16 h; P = .045) change in mean daily CPAP usage at 30 and 90 days, respectively.

Interpretation: Racial discrimination may be a unique psychosocial stressor of future suboptimal CPAP adherence and a potential modifiable target for addressing disparities.

OSA is a chronic condition and one of the leading sleep disorders in the United States. The societal and public health implications of untreated OSA are significant, with high costs associated with undiagnosed OSA in US adults including $86.9 billion because of lost productivity and absenteeism, $30 billion because of associated comorbidities, and $6.5 billion because of occupational accidents.^1,2 Evidence from epidemiologic studies has demonstrated a large prevalence of undiagnosed OSA, particularly among non-Hispanic Black (hereafter Black) adults.³ Black individuals are diagnosed with OSA across the life cycle and are disproportionately affected by cardiovascular disease sequelae of OSA.²

Consistent nightly usage of CPAP remains the criterion standard of treatment for moderate-to-severe OSA; however, it is poorly tolerated and as many as 33% of individuals discontinue treatment within the first year.⁴ One study of Black adults found that based on a validated type three home sleep apnea device, 95% of the sample had OSA, but it was not diagnosed by a provider. In other words, participants had clinically significant and untreated OSA. This suboptimal treatment may partially explain racial and ethnic disparities in OSA-related outcomes including cardiovascular disease sequelae.⁵ For example, a recent study using nationally representative US data demonstrated higher OSA-related mortality and morbidity among Black adults compared with non-Hispanic (hereafter White) adults, which highlights the importance of racial OSA treatment disparities.⁶ Therefore, adherence remains a major public health priority for Black adults.

Psychosocial (eg, social support, self-efficacy) and sociocultural variables (eg, demographics, health literacy) have long been targets for increasing adherence; however, these behavioral-based interventions have not led to significant clinical gains, especially for Black adults diagnosed with OSA.⁷ There remains a dearth of large, randomized trials to eliminate disparities in adherence to CPAP. Although there is a need to identify the optimal strategies to alleviate these disparities, additional work on the myriad of factors contributing to suboptimal adherence is needed. One such area is the role of perceived discrimination, which has been proposed as a robust psychosocial stressor contributing to unhealthy behaviors,⁸ including adverse sleep health.⁹ Given that approximately 32% of Black adults report experiencing discrimination in the health care system,¹⁰ discrimination may affect CPAP adherence. However, to our knowledge, no studies to date have examined the relationship between discrimination and adherence to CPAP. Consequently, the experience of discrimination, a unique sociocultural variable and source of stress, as a potential target to improve adherence to CPAP within the health care system remains unknown.

The current proof-of-concept study was designed to examine the association between discrimination and adherence to CPAP therapy in a sample of Black and White adults newly diagnosed with OSA. To this end, we proposed three hypotheses. First, Black adults would report experiencing greater discrimination than White adults. Second, discrimination would be associated with poorer CPAP adherence over time (30-day and 90-day follow-up), above and beyond self-identified race as Black or White. Third, discrimination would mediate the relationship between self-identified Black race and CPAP usage.

Study Design and Methods

Participants

Participants were approached and invited to participate in the study after completing sleep clinic assessments and diagnostic polysomnography (PSG). The site of recruitment was an urban academic medical center serving primarily insured patients. Participants who self-identified as Black and White, were ≥ 18 years of age, were newly diagnosed with OSA, and had no prior treatment with CPAP were eligible. The analysis for this investigation included only individuals that used CPAP during the first 30 days of therapy and had complete covariate data. Participants who did not use CPAP at all were excluded. Written informed consent was obtained from all participants, and study procedures were conducted in accordance with the Institutional Review Board at NYU Langone Health.

Baseline Questionnaire

Demographics, medical history, and comorbidities were obtained from baseline questionnaires which included sociodemographics (eg, educational level, insurance type), perceived discrimination, daytime sleepiness, insomnia symptoms, and depressive symptoms. Whenever possible, the research assistant conducted a review of the medical record to obtain missing data. CPAP data were collected wirelessly at scheduled follow-up visits.

Race

We use self-identified race throughout this paper to acknowledge the social construct of race and the experience of what it means to be of a particular race in the United States rather than as a biological construct because race in the United States is deeply rooted in systemic racism.¹¹

Polysomnography

Clinically indicated diagnostic PSGs were completed prior to study enrollment per standards established by the American Academy of Sleep Medicine. Scoring was performed manually by a certified sleep technologist, using standardized scoring techniques.¹² Hypopnea scoring followed the recommended definition (≥ 30% reduction in nasal pressure relative to baseline associated with ≥ 4% oxygen desaturation) or arousal. OSA was diagnosed using the International Classification of Sleep Disorders, Third Edition diagnostic criteria.¹² As part of standard of care, CPAP was offered to symptomatic patients with an apnea-hypopnea index (AHI) ≥ 5 per h (with sleep-related symptoms and comorbidities), or AHI ≥ 15 per h without associated sleep-related symptoms.

Research Variable Measures

Everyday Discrimination Scale

The Everyday Discrimination Scale (EDS) has been used widely and is a validated and reliable scale with good internal consistency.^13,14 EDS is a nine-item self-reported frequency of perceived discrimination in daily life.¹³ Respondents are asked the following: In your day-to-day life, how often have the following things happened to you? Examples include the following: people act as though they think you are not smart, and people act as though they think you are dishonest. The items are reported on a six-point Likert scale (1-6: never to almost every day), with higher values indicating more discrimination. For each individual item, discrimination was determined for participants endorsing discrimination a few times a year or more often. Responses are summed across the nine items to produce a score ranging from 9 to 54. Respondents are also asked about the reasons for this discriminatory treatment and can indicate more than one source.

Center for Epidemiological Studies Depression Scale

Depressive symptoms were assessed with the Center for Epidemiological Studies Depression Scale (CES-D). The CES-D consists of 20 questions assessing common depressive symptoms experienced over the prior week.¹⁵ It has been used to assess depressive symptomatology in general population samples with a high internal consistency and test-retest reliability. A CES-D score ≥ 16 was considered suggestive of depression.

Epworth Sleepiness Scale

Subjective daytime sleepiness was determined using the Epworth Sleepiness Scale (ESS), with eight items rated on a scale of 0 to 3, with higher scores indicating a greater propensity of dozing in different situations.¹⁶

Insomnia Severity Index

The Insomnia Severity Index is a seven-item instrument measuring an individual’s perception of their insomnia.¹⁷ The first three items assess difficulties with sleep onset, maintenance, and premature awakenings, whereas the last four items assess daytime consequences of these difficulties. Higher scores indicate more severe insomnia symptoms. The internal consistency, concurrent validity, and sensitivity of the insomnia severity index are well established.

CPAP Adherence

Adherence data were collected via a Cloud provided by the device manufacturer company or from CPAP devices brought to clinical follow-up. Zero use data were corroborated from the CPAP devices to exclude wireless transmission failure or lack of wireless coverage. At follow-up visits, the following adherence variables were extracted from the wireless data cloud or device: (1) percent of days used, (2) percent days used ≥ 4 h, (3) mean daily usage (on all days), (4) residual AHI, and (5) therapeutic CPAP. Mean hours of CPAP usage during the first 30 and 90 days were used as the primary repeated outcome measure.

Data Analysis

Data are reported as means ± SDs to describe continuous variables. Categorical data are presented as frequencies (%). Black and White group comparisons for baseline sociodemographic variables, sleep symptoms, and perceived discrimination were performed with Student t test or χ²/Fisher exact test, as appropriate. To examine the unadjusted association between self-identified Black and White race and adherence at 30 and 90 days, CPAP usage and treatment metrics were compared between the Black and White groups using Student t test.

As part of the premodeling procedure, histograms and frequency distributions of the dependent variables¹⁸ and independent variables (eg, perceived discrimination) were constructed. To examine the predictive value of self-identified race and perceived discrimination for future CPAP usage, linear regression models were constructed. A linear regression model was completed with self-identified Black race and EDS total score as the primary independent variables of interest and mean daily CPAP usage at 30 and 90 days serving as the dependent outcomes. This regression modeling was repeated after adjusting for psychosocial variables known to be associated with CPAP usage (ie, age, educational level, sleepiness, depression).^19,20 The mean daily usage outcome distribution at each time point did not violate normality assumptions. For the dependent and independent variables, Q-Q plots, kurtosis, and skewness were examined.

Finally, EDS total score was explored as a potential mediator of the association between identifying as Black and mean daily CPAP adherence at 30 and 90 days. Mediation analysis was performed using mediation methodology described by Hayes.²¹ The association of (1) self-identified race with EDS score and (2) EDS score with CPAP usage was determined with linear regression. The mediated effect was calculated as the regression coefficient for the association of identifying as Black race with EDS score multiplied by the regression coefficient for the association of EDS score with CPAP adherence adjusted for self-identified race (Fig 1). The point estimate and 95% CI for mediated effects were calculated. All the mediation models were controlled for age, educational level, and depressive symptoms given their known association with CPAP usage.

Figure 1.

A-D, The mediated effect of the Everyday Discrimination Scale score on the association of Black race with CPAP adherence at 90 d. Regression coefficients and 95% CIs are shown: (A) Black race is associated with a 4.5 lower score on the total Everyday Discrimination Scale, representing higher discriminatory experiences. (B) Each 1-unit decrease in the total Everyday Discrimination Scale score (ie, greater discriminatory experience) is associated with 0.06 h (3 min) lower mean daily CPAP usage. (C) The association of Black race with CPAP adherence with and without adjustment for total Everyday Discrimination Scale. (D) The mediated effect of total Everyday Discrimination Scale score on the association of Black race with CPAP usage is 16.2 min (0.27 h). The higher discriminatory experiences reported by Black participants accounts for 16 min of reduced CPAP usage.

For all analyses, P < .05 was accepted as statistically significant. Statistical analyses were performed with SPSS Statistics 27.0 (SPSS Inc), whereas tables and figure were created with JASP version 0.14.1.²²

Results

Sample Characteristics and Black-White Group Comparisons

Seventy-eight participants (31% female, 38% Black) with a mean age of 57 ± 14 years were included in this analysis. Fifteen participants (seven Black adults) were excluded because they discontinued CPAP therapy during the first month of treatment without racial differences in the proportion of people excluded (19% vs 17%, P = .60). Relative to White adults, Black participants were younger, were less likely to be married, had Medicare insurance coverage, and were less likely to have a Bachelor’s or other higher educational degree (Table 1). Black adults also reported significantly greater depressive symptoms and higher subjective levels of sleepiness than White adults. Black-White comparisons of discrimination are depicted in Table 2. Black adults experienced discrimination significantly more often than White adults in most situations. The only items that did not show significant Black-White differences were the following: people act as if they think you are dishonest, you are called names or insulted, and you are threatened or harassed. As such, the EDS total score was lower among Black adults than White adults (44 ± 9 vs 50 ± 5, respectively; P ≤ .001). Sixty percent of the Black adults reported that they experienced racial discrimination at least a few times a year. Relative to White adults, Black participants were also more likely to report more than one reason for experiencing discrimination (27% vs 4%, P = .003). In addition to race, Black adults also reported that they experienced significantly higher frequency of discrimination based on age, weight, skin color, and ancestry than White adults.

Table 1.

Comparisons of Baseline Characteristics by Race

Characteristic	All Participants (N = 78)	Black Participants (n = 30)	White Participants (n = 48)	P Value
Demographics
Age, y	57 ± 14	52 ± 12	60 ± 14	.006
Sex, female	24 (31)	11 (37)	13 (27)	.37
Marital status, married	37 (47)	9 (30)	28 (58)	.015
Highest education level, Bachelor’s degree or higher	55 (71)	14 (47)	41 (85)	< .001
Employment status, employed	46 (59)	17 (57)	29 (60)	.79
Insurance typea
Private	40 (51)	14	26	.519
Medicare	33 (42)	8	25	.027
Medicaid	9 (12)	6	3	.080
Questionnaires
Depression (CES-D)	13 ± 11	17 ± 12	10 ± 9	.003
Epworth Sleepiness Scale	9 ± 5	11 ± 6	8 ± 4	.017
Insomnia severity index	13 ± 7	14 ± 7	12 ± 6	.076

Values are No. (%), mean ± SD, or as otherwise indicated. Boldface values represent P < .05. Group comparisons made per Student t test or χ² test, as appropriate. CES-D = Center for Epidemiological Studies Depression Scale.

^aParticipants could report more than one insurance source.

Table 2.

Comparisons of Everyday Discrimination Scale by Race

	All Participants (N = 78)	Black Participants (n = 30)	White Participants (n = 48)	P Value
Prevalencea of discrimination by situation
Treated with less courtesy than others	24 (31)	16 (53)	8 (17)	< .001
Treated with less respect than others	23 (29)	15 (50)	8 (17)	.002
Receive poorer service at restaurants/stores	16 (21)	11 (37)	5 (10)	.005
People act as if they think you are not smart	11 (14)	8 (27)	3 (6)	.018
People act as if they are afraid of you	11 (14)	8 (27)	3 (6)	.018
People act as if they think you are dishonest	5 (6)	3 (10)	2 (4)	.367
People act as if they are better than you are	20 (26)	14 (47)	6 (13)	< .001
You are called names or insulted	7 (9)	2 (7)	5 (10)	.701
You are threatened or harassed	7 (9)	5 (17)	2 (4)	.100
Everyday Discrimination Scale total score	48 ± 8	44 ± 9	50 ± 5	< .001
Etiology of discriminatory experiences
Race	19 (24)	18 (60)	1 (2)	< .001
Age	8 (10)	6 (20)	2 (4)	.049
Sex	8 (10)	4 (13)	4 (8)	.476
Weight	8 (10)	7 (23)	1 (2)	.004
Skin color	6 (8)	5 (17)	1 (2)	.029
Ancestry/national origin	7 (9)	6 (20)	1 (2)	.012
Religion	4 (5)	2 (7)	2 (4)	.636

Values are No. (%), mean ± SD, or as otherwise indicated. Boldface values represent P < .05. Group comparisons made per Student t test or χ²/Fisher exact test, as appropriate.

^aDiscriminatory experiences reported a few times a year or more often. The seven most common etiologies of discrimination are listed. Others included education/income level (n = 3), height (n = 3), another physical attribute (n = 3), physical disability (n = 2), and sexual orientation (n = 1).

Black-White Cross-Sectional CPAP Adherence Comparisons at 30 and 90 Days

As shown in Table 3, significant racial CPAP usage differences were observed after 30 and 90 days of treatment. After 30 days, Black adults used CPAP on significantly fewer days (20.6 ± 6.7 vs 26.4 ± 5.8 days, P < .001) and, on average, shorter amounts of time (3.7 ± 1.8 vs 5.6 ± 2.0 h, P < .001) than White adults, respectively. These significant differences in CPAP adherence persisted and widened over time. Specifically, after 90 days of therapy, the mean daily usage among Black adults was > 2 h less than those of White participants (3.0 ± 1.8 vs 5.2 ± 2.3 h, respectively; P < .001). After the initial 30 days of therapy, the residual AHI was significantly lower among Blacks adults than White participants but was similar after 90 days of treatment. There were no significant Black-White differences in therapeutic CPAP at both time points.

Table 3.

Comparisons of CPAP Metric by Race After 30 and 90 Days of Therapy

CPAP Characteristic	30 d			90 d
	Black Participants (n = 30)	White Participants (n = 48)	P Value	Black Participants (n = 30)	White Participants (n = 48)	P Value
Days used	20.6 ± 6.7	26.4 ± 5.8	< .001	48.8 ± 25.6	74.2 ± 23.7	< .001
Days ≥ 4 h, %	44 ± 25	67 ± 32	.002	36 ± 23	63 ± 28	< .001
Mean daily usage, h	3.7 ± 1.8	5.6 ± 2.0	< .001	3.0 ± 1.8	5.2 ± 2.3	< .001
Residual AHI	3.3 ± 3.9	5.4 ± 4.5	.036	4.3 ± 5.2	4.6 ± 3.6	.781
CPAP, cm H2O	7.1 ± 2.9	6.7 ± 2.7	.532	7.4 ± 3.1	6.9 ± 2.9	.585

Data are presented as mean ± SD or as otherwise indicated. Boldface values represent P < .05. Group comparisons made per Student t test. AHI = apnea-hypopnea index (events/h of sleep).

Self-Identified Race and Discrimination Predict CPAP Usage at 30 and 90 Days

Hierarchical linear regression models were constructed to determine the unique associations between Black race, perceived discrimination, and mean daily CPAP usage at 30 and 90 days (Table 4). While adjusting for discrimination, Black race was associated with 1.4 (95% CI, −2.3 to −0.4 h; P = .006) and 1.6 (95% CI, −2.6 to −0.6 h; P = .003) fewer hours of mean daily CPAP usage at 30 and 90 days, respectively. Similarly, regardless of race, the total discrimination score (lower discrimination) was significantly associated with higher CPAP usage at these time periods. However, with further adjustment for demographic and psychosocial variables, self-identified Black race was no longer significantly associated with CPAP usage (30-day β = −0.8 h; 95% CI, −1.9 to 0.20 h; P = .14; 90-day β = −1.1 h; 95% CI, −2.3 to 0.10 h; P = .07), but the association with discrimination score persisted. In the fully adjusted model, a 1-unit change in total discrimination score (more discrimination) was associated with 0.08-h (95% CI, 0.01-0.15 h; P = .029) and 0.08-h (95% CI, 0.01-0.16 h; P = .045) change (approximately 5-min change) in mean daily CPAP usage at 30 and 90 days, respectively. Therefore, someone experiencing daily racial discrimination would be predicted to usage CPAP for about 30 min less, on average, in the future than someone not experiencing racial discrimination.

Table 4.

Regression Analyses of Association Between Black Race and Discrimination on Mean Daily CPAP Usage

	30 d			90 d
	Model 1	Model 2	Model 3	Model 1	Model 2	Model 3
Black race	−1.4 (−2.3 to −0.4)	−1.0 (−2.0 to 0.10)	−0.8 (−1.9 to 0.20)	−1.6 (−2.6 to −0.6)	−1.3 (−2.5 to −0.20)	−1.1 (−2.3 to 0.10)
Everyday Discrimination Scale score	0.09 (0.02 to 0.15)	0.09 (0.02 to 0.15)	0.08 (0.01 to 0.15)	0.08 (0.01 to 0.15)	0.09 (0.02 to 0.16)	0.08 (0.01 to 0.16)

Values are β (95% CI). Boldface values represent P < .05. Model 1 includes Black race and total Everyday Discrimination Scale score. Model 2 includes model 1 plus age and educational level. Model 3 includes model 2 plus depressive symptoms (Center for Epidemiological Studies Depression Scale score) and sleepiness (Epworth Sleepiness Scale score).

Perceived Discrimination Mediates Some of the Relationship Between Self-Identified Black Race and CPAP Usage

To examine whether baseline perceived discrimination was an intermediary pathway for the association between self-identified race and CPAP adherence, EDS score was examined as a mediator for the association of self-identified Black race with future CPAP usage (Fig 1). After 90 days of treatment, in analyses adjusted for age, educational level, and depressive symptoms, Black participants used CPAP 1.4 h less than White adults, on average. The mediated effect of discrimination on the association of self-identified Black race with mean daily CPAP adherence was −0.27 h (95% CI, −0.66 to −0.01; P = .045). Perceived discrimination mediated a similar proportion of the CPAP usage difference between Black and White adults after 30 days of therapy (data not shown). Therefore, the higher discrimination experiences reported by Black participants accounted for approximately 16 min of reduced CPAP usage after 3 months of therapy initiation.

Discussion

To our knowledge, the association between individual-level discrimination because of race and adherence to CPAP has not been previously documented. As anticipated, experiences of discrimination were more commonly reported among Black adults than White adults. We did not observe a significant difference at the 7-day follow-up. After 30 days, participants reporting discrimination used CPAP on significantly fewer days and for shorter duration. These differences in CPAP adherence persisted and widened over time including at the 90-day follow-up. Also, discrimination explained a small amount of the 1.4-h difference between Black and White adults after 3 months of therapy. Another study had similar results when examining sleep duration as a potential mediator. In that study, sleep duration explained 11.3 min of the difference in CPAP usage between Black and White adults.²³ The study did not assess discrimination, but suggested neighborhood factors contribute to the Black-White difference. Nonetheless, these results demonstrate the complexity of adherence disparities.

Importantly, these differences were observed after controlling for depressive symptoms. Previous research has observed that only about 60% of adults regularly use CPAP after 1 year,²⁴ and there is a consistent decrease in persistent usage over time. The pattern observed in our study is that CPAP usage decreases more rapidly among people who experience discrimination (albeit a low number of individuals reported discrimination). Because discrimination is a source of chronic stress, individuals experiencing discrimination may engage in avoidant or maladaptive coping behaviors, which may impede adherence behavior.²⁵ If these findings are replicated, the implications are that in the long term, perceived racial discrimination may position Black adults with continued suboptimal adherence at risk for OSA sequela, and therefore widening OSA-related health disparities. Experiences of racial discrimination have detrimental effects on sleep health more broadly, but more work is needed to understand how this unique stressor may impact health behaviors for OSA therapy, particularly among Black adults.^9,26 Discrimination may mediate worse CPAP usage via curtailed sleep duration, greater insomnia symptoms (making CPAP less tolerable), or other means. Understanding better that discrimination could impact adherence behavior supports other models on stressors and health maintenance behaviors. For example, Forsyth et al²⁵ conducted a mediation analysis and found a direct relationship between discrimination and medication adherence, which was partly explained by stress and depression. In the absence of addressing structural forms discrimination (eg, education, neighborhood, socioeconomic status), there are several strategies to be considered. First, members of a health care team may consider developing trusting and equitable relationships for those who report nonadherence.²⁷ Another important strategy is to assess the degree to which stereotyping and implicit bias (unintentional expressions of discrimination) predict medical encounters with Black patients.²⁸ A strong body of evidence has highlighted the role of health care providers’ bias and stereotyping in health outcomes.²⁹ Health care providers’ implicit bias could negatively impact patients’ therapy adherence and follow-up visits. A recent call to action in the medical field, which is ripe for behavioral sleep medicine, emphasizes structural competency or the ability to articulate how social structures produce racial, ethnic, gender, class, and other disparities to better serve vulnerable populations through self-awareness and empathy.³⁰ Other modifiable and practical solutions should be explored. For example, group counseling interventions intended to enhance hope, another psychosocial internal resource, are successful in improving well-being³¹ and a range of health benefits.^32,33 Finally, these findings should provoke policy change about adherence. The adherence threshold used by the Centers for Medicare & Medicaid Services (CMS) and most insurance providers as the criteria for CPAP reimbursement has not been robustly evaluated. The patient must fulfil these requirements for continuation of CPAP therapy after the initial 90-day period. If the patient fails to satisfy these requirements, CPAP therapy is considered failed and requires a new sleep study after first failure.²⁰ It is certainly plausible that there is an undue burden on minoritized populations and lower-income adults with OSA with respect to this policy. Current CMS policy may have unintended consequences and thwart any advancements in health equity. Community, faith, patient advocacy, and even labor organizations could join to advocate for the repeal of the CMS policy.

Our analysis was restricted to racial discrimination because it is the most pervasive form of discrimination reported by Black patients in the United States maintaining inequities in health care and an important determinant of health care utilization.³⁴ We also recognize that the scoring methodology can impact these exposures, rather as dichotomous or continuous.^28,29 Both EDS scoring methods are known to underestimate experiences of discrimination. Our study was not powered to address multiple forms of discrimination, and eight people experiencing racial discrimination also endorsed other sources of discrimination. It is noteworthy that participants who experienced discrimination reported low education. Although this is consistent with the literature on discrimination and low education among the general population, the pattern is reversed in health care encounters with Black adults, with high education and higher income reporting more experiences of discrimination.^35,36 The small sample size limited our ability to tease apart the potential interaction effects of education and other demographic factors (eg, marital status) and psychosocial covariates that may deepen our understanding of these findings.

Interpretation

Few studies have examined the impact of perceived discrimination, despite the fact that numerous psychosocial variables including social support and self-efficacy have been found to influence CPAP usage through complex interactions.³⁷ These findings suggest that the experience of discrimination (eg, being treated with less respect) rather than individuals’ race contributes to suboptimal adherence. Therefore, considering the effects of discrimination as a psychosocial stressor allows for a more nuanced understanding of Black-White disparities in adherence to CPAP. The efficacy of conventional strategies to address adherence including motivational enhancement has been mixed.^4,38 Mitigating the adverse effect of discrimination is complex, and it might be necessary to investigate novel targets that may counteract the negative impact of discrimination on adherence among Black adults with OSA.

Funding/Support

N. J. W. was supported by the National Institutes of Health [Grants K23HL125939, K23HL125939-S1].

Financial/Nonfinancial Disclosures

None declared.