Table 1.
Description of the Processes of Patient Engagement in the MetSO Tailored Behavioral Intervention.
| MetSO Intervention Implementation (Phase I) |
| • The objective of the first contact was to assess knowledge, attitudes, and behaviors related to sleep and to improve patients’ understanding of OSA and the need for initial consultations and evaluations. Within 2 weeks of enrollment, the educator contacted each patient, providing a brief introduction and reiterating the purpose of the trial. The educator then proceeded to address barriers based on patients’ level of knowledge, perceived risk, and stage of readiness. During phone conversations, threatening, frightening, or judgmental statements were avoided. Rather, the educator emphasized positive reinforcement and enhancement of perceived self-efficacy to ensure desired behavior change. At the end of each call, the educator prompted patients for a verbal commitment to seek OSA care. Once a commitment was made, the educator contacted the sleep clinic to determine whether the patients had a consultation and evaluation and whether treatment has been prescribed if they were diagnosed. |
| • The decision not to adhere to recommended OSA care may be motivated by reasons that are not immediately apparent. Although a patient may have necessary knowledge for positive actions, negative emotions (eg, fear and denial) can influence their decision not to seek care. Thus, such emotions had to be acknowledged and addressed. Individual tailoring relied on an iterative process in which the educator considered patients’ incentives facilitating OSA evaluation and barriers limiting desired behaviors. Thus, the educator attempted to maximize the incentives and overcome identified barriers. Once the educator understood why a patient was not adhering, she endeavored to tailor the TTI to the patient’s stage of readiness, feelings, and ways of reasoning. For some patients, the educator tailored the TTI to increase their OSA knowledge. Others required assistance in overcoming deficits in self-efficacy through coaching and role-playing. Individual tailoring often required patience, particularly when patients had time constraints due to personal/familial challenges. For patients dealing with health problems, the educator was empathetic and understanding. For those beset by fear and denial, social and emotional support was necessary. |
| • For patients who did not keep their appointment, the educator would again attempt to elicit a verbal commitment to schedule one. The educator attempted to identify obstacles and worked jointly with the patients to overcome them. The cycle would be repeated until an initial consultation or evaluation was obtained. If appointments were kept, a positive reinforcing message was provided. For patients who reported that no diagnosis was made, they were congratulated and thanked and the intervention ended at that time; this was verified through chart reviews. |
| MetSO Intervention Implementation (Phase II) |
| • For patients who reported a diagnosis, the educator focused on three main questions: 1) Did the doctor say that you have OSA? 2) What therapy, if any, was suggested? and 3) Were you asked to go back for a follow-up visit? When? Those patients then moved to Phase II, where the focus was on treatment adherence. |
| • The TTI approach during Phase II was similar to Phase I. The main theme was to foster a certain level of comfort and confidence so that patients become accustomed to using positive airway pressure (PAP) therapy. The educator approached OSA as a chronic disease, requiring adequate self-management. Patients who indicated that they had received a diagnosis received a call to discuss the significance of the diagnosis and treatment recommendations. More importantly, the educator determined whether arrangements for such care had been made through the sleep clinic. If follow-up care was obtained, the educator identified obstacles and worked jointly with the patients to formulate strategies for overcoming such obstacles. The educator endeavored to enhance patients’ comfort and confidence using PAP until the end of the 6-month period when outcome ascertainment occurred. |
| • In cases where resistance to treatment was encountered, the educator provided further education on the benefits of PAP therapy including reduced daytime sleepiness, arterial blood desaturations, heart attack and pulmonary pressure, improved cognitive performance, increased quality of well-being, and longer survival. The educator addressed factors known to affect PAP adherence, including mask tolerance, nasal- related complaints, reduced motility as well as potential side effects such as facial skin discomfort, nasal stuffiness, rhinitis, and inability to tolerate the pressure. The educator encouraged patients to discuss the benefits of treating nasal congestion with heated humidification or nasal medications with their doctor, when necessary. The educator also highlighted the gains patients have experienced since initiating PAP. |
OSA, obstructive sleep apnea; TTI, telephone-delivered treatment intervention.