Abstract
Objective:
The aim is to study the knowledge and attitude of medical undergraduate students regarding obstructive sleep apnea (OSA).
Materials and Methods:
This cross-sectional study involved 324 medical undergraduate students in clinical semesters. Knowledge and attitude regarding adult OSA were assessed using the obstructive sleep apnea knowledge and attitude (OSAKA), and to evaluate the same about childhood OSA, OSAKA-KIDS was used.
Results:
Results showed that the study population was not informed about OSA among adults as well as kids. Most of the participants could recognize that snoring was a common symptom of adult OSA but failed to identify the association between childhood OSA and hyperactivity. The participants had a good knowledge about the pathophysiology of OSA. More than 80% of students reported that OSA is an important disorder and that these patients should be identified.
Conclusion:
Medical undergraduates are poorly informed about OSA.
Keywords: Attitudes, knowledge, obstructive sleep apnea
INTRODUCTION
Sleep disorders are prevalent and are seen across all age groups. These disorders vary in clinical presentation and pathophysiology. However, all of them are known to disrupt sleep and have adverse consequences on health, functioning, and quality of life. For example, obstructive sleep apnea (OSA), which has a prevalence of 9.3% among adults and 7.5% among children, has been found to be a risk factor for metabolic syndrome, diabetes mellitus, coronary artery disease, stroke, and cognitive impairment.[1,2,3] Interestingly, treatment of OSA has been found to improve sleep, mood, cognition, glycemic control, and blood pressure.[4,5,6,7]
Direct and indirect costs of untreated sleep disorders are huge and result from the disease itself, comorbid illness, work absenteeism, accidents related to sleep disorders, and reduced productivity.[8] Despite such adverse health consequences and economic impact, awareness regarding these common sleep disorders among physicians is limited.[9,10,11,12,13,14,15,16] Previous studies have assessed knowledge, attitude, and practice related to OSA among dentists,[9] physicians,[11] dental-hygienist, and[17] anesthetists.[18] These studies have reported that most of the medical students lacked knowledge important to diagnose and manage OSA among adults as well as kids.
Earlier studies have assessed knowledge and attitude regarding OSA among health professionals using validated tools-obstructive sleep apnea knowledge and attitude (OSAKA) and OSAKA-KIDS.[19,20] These studies have included practicing health professionals and specialists, but only three studies have evaluated it among medical students.[21,22,23]
The prevalence of OSA in the Indian population is much higher than other psychiatric disorders such as depression and anxiety, which have found a place in the curriculum for Indian Medical Graduates.[24,25,26,27] Despite these facts, common sleep disorders are not included in the latest curriculum for Indian Medical Graduate.[24,25,26] Further, as discussed above, OSA is associated with a number of negative health outcomes, including the metabolic, cardiovascular, decline in quality of life, and at times either mitigate or pave the way for psychiatric disorders.[1,2,3,28] Timely recognition and optimal management of OSA can improve these health conditions and also prevent negative health effects.[4,5,6,7] Hence, authors feel that the inclusion of sleep medicine topics in the medical undergraduate curriculum will be instrumental in providing help to a large chunk of patients suffering from these disorders.[21]
Considering all these issues, the present study is aimed at assessing knowledge, attitude, and practice related to OSA (adults and kids). These disorders are missing from the recently revised curriculum by the Medical Council of India in both knowledge as well as skill domains.[24,25,26]
MATERIALS AND METHODS
This study was done among final year medical graduates who were studying clinical subjects such as general medicine and otorhinolaryngology in addition to psychiatry. The sample size was not calculated, and study involved all students that were present in the class. The use of any material that could provide help in responding to items (books or mobile phone) was barred. Approval from the Institutional Ethics Committee was obtained. All students of clinical semesters were invited to participate in this study after explaining the rationale. Students were given questionnaires in their classrooms without having prior knowledge about the content of the questionnaire and, were requested to mark the most appropriate responses on each of the questionnaires. It was explained beforehand that responses on these questionnaires would not be included in their regular academic assessment. For assessing knowledge related to OSA, standardized questionnaires-OSAKA[19] and OSAKA-Kids[20] were used after obtaining permission.
Obstructive sleep apnea knowledge and attitude assessment:
OSAKA questionnaire contains 18 items that are scored as “yes, no” or “don't know.” “Don't know” is also considered as an incorrect response.[19] These items gather information regarding epidemiology, pathophysiology, clinical presentation, diagnosis, and the management of OSA. In addition, it contains five other statements that assess the importance and ability to diagnose OSA. These items are scored on a five-point Likert's scale. This has an internal consistency of 0.76.
Obstructive sleep apnea knowledge and attitude-KIDS
OSAKA-KIDS is a 23 - questionnaire that has been developed to assess physician's knowledge related to childhood OSA syndrome.[20] Similar to OSAKA, it has 18 items assessing knowledge, i.e., epidemiology, pathophysiology, clinical picture, diagnosis, and complications of pediatric OSA. These are scored as “yes, no” or “don't know.” Similar to OSAKA, “don't know” is considered an incorrect response. In addition, it contains five other statements that assess the importance and ability to diagnose OSA. These items are scored on a five-point Likert's scale.
Statistical analysis
The analysis was done using SPSS version 23 (IBM Corp. Released 2015. IBM SPSS Statistics for Windows, version 23.0. Armonk, NY, USA: IBM Corp.) The frequency of each response on items of questionnaires was calculated. The proportion of subjects who provided correct responses was also calculated for various items of three questionnaires that were also computed. Chi-square test was used to calculate the significance of probability for categorical variables.
RESULTS
This study included a total of 324 medical students in the final year (clinical semesters) of undergraduate course (MBBS) in three institutes. Six students chose not to take part in this study. The mean age of students was 23.1 ± 2.6 years.
On the attitude items of OSAKA, 85.08% of students responded that OSA is important to extremely important as a clinical disorder, and 90.74% reported that identifying patients with possible OSA was important to extremely important. 22.53% of students were confident in identifying patients with OSA, 15.74% felt that they could manage patients with OSA, and 16.66% were confident that they could institute continuous positive airway pressure (CPAP) therapy. Interestingly, students considered OSA during childhood to be as important as adult OSA. 81.17% considered OSA among kids as important to extremely important disorder, 82.09% felt that identifying children with OSA was important to extremely important. 18.82% felt confident in identifying children with OSA, 16.66% opined that they could manage childhood OSA, and 17.90% responded that they could manage CPAP therapy among children with OSA. Responses to individual items are shown in Tables 1 and 2.
Table 1.
Response to individual items on obstructive sleep apnea knowledge and attitude (n=324)
Item | Response | Correct response (%) | ||
---|---|---|---|---|
Yes | No | Don’t know | ||
Female present with fatigue | 189 | 44 | 91 | 189 (58.33) |
Uvulopalatoplasty is curative | 166 | 50 | 108 | 50 (15.43) |
OSA prevalence 2%-10% | 109 | 52 | 163 | 109 (33.64) |
OSA are snorers | 237 | 45 | 42 | 237 (73.14) |
OSA associated with HTN | 150 | 55 | 119 | 150 (46.29) |
PSG diagnoses OSA | 208 | 49 | 67 | 208 (64.19) |
CPAP causes nasal stuffiness | 115 | 64 | 135 | 115 (35.49) |
Laser-assisted uvulopalatoplasty | 149 | 41 | 134 | 149 (45.98) |
Loss of pharyngeal muscle tone causes OSA | 189 | 55 | 80 | 189 (58.33) |
Adenoid tonsil enlargement causes OSA in children | 211 | 46 | 67 | 211 (65.12) |
Craniofacial exam important in OSA | 208 | 33 | 83 | 208 (64.19) |
Alcohol improves OSA | 51 | 156 | 117 | 156 (48.14) |
OSA associated with accidents | 182 | 45 | 97 | 182 (56.17) |
Collar size >17 in OSA | 90 | 54 | 180 | 90 (27.77) |
OSA commoner in females | 113 | 89 | 122 | 89 (34.87) |
CPAP is first line therapy | 135 | 54 | 135 | 135 (41.66) |
AHI <5 is normal | 80 | 109 | 135 | 80 (24.69) |
OSA may cause arrhythmias | 159 | 24 | 141 | 159 (49.07) |
OSA – Obstructive sleep apnea; PSG – Polysomnography; HTN – Hypertension; CPAP – Continuous positive airway pressure; AHI – Apnea-hypopnea index
Table 2.
Response to individual items on obstructive sleep apnea knowledge and attitude-KIDS (n=324)
Items | Responses | Correct response (%) | ||
---|---|---|---|---|
Yes | No | Don’t know | ||
Children with (OSA) may be hyperactive | 172 | 53 | 99 | 172 (53.08) |
10% of children snore | 244 | 60 | 20 | 244 (75.30) |
2% children have OSA | 252 | 61 | 11 | 252 (77.77) |
OSA in children may cause pulmonary hypertension | 231 | 40 | 53 | 231 (71.29) |
PSG is needed to differentiate primary snoring from OSA | 268 | 30 | 26 | 268 (82.71) |
Degree of snoring correlates with severity of OSA | 102 | 141 | 81 | 141 (43.51) |
Loss of upper airway muscle tone contributes to OSA | 232 | 72 | 20 | 232 (71.60) |
Adenotonisllar hypertrophy causes OSA | 263 | 30 | 31 | 263 (81.17) |
head and neck and oropharyngeal examination is required | 251 | 42 | 31 | 251 (77.46) |
OSA may cause learning defects | 236 | 67 | 21 | 236 (72.83) |
Snoring is most frequently reported at ages 2-8 years | 169 | 106 | 49 | 106 (32.71) |
Cardiac arrhythmias may be associated with untreated OSA | 201 | 101 | 22 | 201 (62.03) |
Sickle cell disease increases risk of OSA | 143 | 100 | 81 | 143 (44.13) |
PSG required before surgery for presumed OSA | 218 | 96 | 10 | 218 (67.28) |
OSA can occur without snoring | 231 | 67 | 26 | 231 (71.29) |
Failure to thrive is a frequent complication of OSA | 221 | 51 | 52 | 221 (68.20) |
Transient worsening of respiratory symptoms following adenotonsillar surgery | 223 | 40 | 61 | 223 (68.82) |
Cardiorespiratory monitor can reliably detect OSA and CSA | 202 | 104 | 18 | 104 (32.09) |
OSA – Obstructive sleep apnea; PSG – Polysomnography; CSA – Central sleep apnea
DISCUSSION
This study showed that knowledge related to OSA [Tables 1 and 2] was limited among medical students, particularly regarding pathophysiology, risk factors, and management. Despite having limited knowledge, most of the students felt that OSA is an important disorder, and these patients should be identified.
Most of the students in the present study recognized that snoring was an important symptom for adult OSA; that polysomnography was required for diagnosis and that craniofacial examination is important in these patients. Results of the present study corroborate with that of the previous studies from similar geographic regions, such as Ecuador and Nigeria.[21,22,23] All the studies have shown that students have adequate knowledge regarding the pathophysiology of adult OSA; however, most of them were incorrect about the role of CPAP and uvulopalatoplasty in the treatment of OSA.[21,22] Considering the prevalence and burden of OSA, medical graduates should be given training regarding basic principles of management of the same.
Students in a previous study appeared to have better knowledge about OSA among children, especially the role of adenotonsillar hypertrophy, role of muscle tone, and need for craniofacial examination, findings similar to which are seen in the present study as well.[21] In addition, students in the present study seemed to have better knowledge about the role of polysomnography in the diagnosis of childhood OSA. However, students in both the studies were unaware of hyperactivity as a symptom of OSA among children. This is an important issue as a meta-analysis suggested that the attention-deficit-hyperactivity-disorder (ADHD) symptoms may be causally associated with OSA.[29] Interestingly, in this analysis, studies of either type were included-those that assessed ADHD among children with OSA as well as those evaluating OSA among children with ADHD.[29] Further, it was concluded that children with ADHD should be screened for OSA and be treated before starting medications for ADHD.[29]
All previous studies have argued that information regarding OSA should be included in the medical undergraduate curriculum.[21,22] However, sleep medicine is not considered as important in the undergraduate curriculum by nearly half of the medical teachers in India.[30] This could be one reason why this has not been included in the medical curriculum till now.[30] The situation is not different across countries and even the most developed countries designate nearly 3 h to sleep medicine topics during undergraduate medical teaching.[31] Situation in the residency program is also not better, and it has been found that in the pediatric residency program, only 4.4 h are dedicated to sleep medicine.[32] This should be seen with the background that most of the medical students in the present study responded that OSA is an important medical condition and that identifying these patients is important, corroborating with the results of earlier studies.[21,23]
Results of the present study are important in the context of patients with OSA being seen and often missed in clinics such as psychiatry, neurology, cardiology, internal medicine, surgery, endocrinology and anesthesia because of comorbidities.[33,34,35] In addition, similar to Goyal et al.,[21] we also opine that considering the high prevalence of sleep disorders, at least the medical colleges must be equipped with sleep-laboratory and at least one faculty in each medical college should opt for sleep medicine.
Like any other scientific study, this study also had some methodological limitations. First, the study was cross-sectional. Results are likely to change after the study participants gather information regarding these disorders. Second, results show the present situation in three institutions and may not be applicable to other institutes where module for sleep medicine has already been included in the medical undergraduate curriculum.
CONCLUSION
The present study suggested that undergraduate students in clinical semesters have inadequate information regarding OSA.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgments
We are also thankful to Dr. Helena Schotland for allowing us to use OSAKA and OSAKA-KIDS in this study.
REFERENCES
- 1.Reddy EV, Kadhiravan T, Mishra HK, Sreenivas V, Handa KK, Sinha S, et al. Prevalence and risk factors of obstructive sleep apnea among middle-aged urban Indians: A community-based study. Sleep Med. 2009;10:913–8. doi: 10.1016/j.sleep.2008.08.011. [DOI] [PubMed] [Google Scholar]
- 2.Gupta R, Ali R, Verma S, Joshi K, Dhyani M, Bhasin K, et al. Study of sleep disorders among young children using Hindi translated and validated version of pediatric sleep questionnaire. J Neurosci Rural Pract. 2017;8:165–9. doi: 10.4103/jnrp.jnrp_428_16. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.American Academy of Sleep Medicine. International Classification of Sleep Disorders. 3rd ed. Darian, IL: American Academy of Sleep Medicine; 2014. [Google Scholar]
- 4.Orr JE, Smales C, Alexander TH, Stepnowsky C, Pillar G, Malhotra A, et al. Treatment of OSA with CPAP is associated with improvement in PTSD symptoms among veterans. J Clin Sleep Med. 2017;13:57–63. doi: 10.5664/jcsm.6388. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Hu X, Fan J, Chen S, Yin Y, Zrenner B. The role of continuous positive airway pressure in blood pressure control for patients with obstructive sleep apnea and hypertension: A meta-analysis of randomized controlled trials. J Clin Hypertens (Greenwich) 2015;17:215–22. doi: 10.1111/jch.12472. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Cooke JR, Ayalon L, Palmer BW, Loredo JS, Corey-Bloom J, Natarajan L, et al. Sustained use of CPAP slows deterioration of cognition, sleep, and mood in patients with Alzheimer's disease and obstructive sleep apnea: A preliminary study. J Clin Sleep Med. 2009;5:305–9. [PMC free article] [PubMed] [Google Scholar]
- 7.Dalmases M, Solé-Padullés C, Torres M, Embid C, Nuñez MD, Martínez-Garcia MÁet al. Effect of CPAP on cognition, brain function, and structure among elderly patients with OSA: A randomized pilot study. Chest. 2015;148:1214–23. doi: 10.1378/chest.15-0171. [DOI] [PubMed] [Google Scholar]
- 8.Skaer TL, Sclar DA. Economic implications of sleep disorders. Pharmacoeconomics. 2010;28:1015–23. doi: 10.2165/11537390-000000000-00000. [DOI] [PubMed] [Google Scholar]
- 9.Jokubauskas L, Pileičikienė G, žekonis G, Baltrušaitytė A. Lithuanian dentists' knowledge, attitudes, and clinical practices regarding obstructive sleep apnea: A nationwide cross-sectional study. Cranio. 2019;37:238–45. doi: 10.1080/08869634.2018.1437006. [DOI] [PubMed] [Google Scholar]
- 10.Gruber R, Constantin E, Frappier JY, Brouillette RT, Wise MS. Training, knowledge, attitudes and practices of Canadian health care providers regarding sleep and sleep disorders in children. Paediatr Child Health. 2017;22:322–7. doi: 10.1093/pch/pxx069. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Ozoh OB, Ojo OO, Iwuala SO, Akinkugbe AO, Desalu OO, Okubadejo NU. Is the knowledge and attitude of physicians in Nigeria adequate for the diagnosis and management of obstructive sleep apnea? Sleep Breath. 2017;21:521–7. doi: 10.1007/s11325-016-1407-z. [DOI] [PubMed] [Google Scholar]
- 12.Sia CH, Hong Y, Tan LW, van Dam RM, Lee CH, Tan A. Awareness and knowledge of obstructive sleep apnea among the general population. Sleep Med. 2017;36:10–7. doi: 10.1016/j.sleep.2017.03.030. [DOI] [PubMed] [Google Scholar]
- 13.Ozoh OB, Ojo OO, Iwuala SO, Akinkugbe AO, Desalu OO, Okubadejo NU. Is the knowledge and attitude of physicians in Nigeria adequate for the diagnosis and management of obstructive sleep apnea? Sleep Breath. 2016;21:521–7. doi: 10.1007/s11325-016-1407-z. [DOI] [PubMed] [Google Scholar]
- 14.Camargo EP, Carvalho LB, Prado LB, Prado GF. Is the population properly informed about sleep disorders? Arq Neuropsiquiatr. 2013;71:92–9. doi: 10.1590/s0004-282x2013005000001. [DOI] [PubMed] [Google Scholar]
- 15.Cherrez Ojeda I, Jeffe DB, Guerrero T, Mantilla R, Santoro I, Gabino G, et al. Attitudes and knowledge about obstructive sleep apnea among Latin American primary care physicians. Sleep Med. 2013;14:973–7. doi: 10.1016/j.sleep.2013.06.005. [DOI] [PubMed] [Google Scholar]
- 16.Wang CL, Li XZ, Cai XL, Pan XL, Min J. Anesthesiologist's knowledge and attitudes about obstructive sleep apnea: A survey study. Sleep Breath. 2012;16:41–6. doi: 10.1007/s11325-011-0482-4. [DOI] [PubMed] [Google Scholar]
- 17.Reibel YG, Pusalavidyasagar S, Flynn PM. Obstructive Sleep Apnea Knowledge: Attitudes and screening practices of Minnesota dental hygienists. J Dent Hyg. 2019;93:29–36. [PubMed] [Google Scholar]
- 18.Corso RM, Sorbello M, Buccioli M, Carretta E, Nanni O, Piraccini E, et al. Survey of knowledge and attitudes about obstructive sleep apnoea among Italian anaesthetists. Turk J Anaesthesiol Reanim. 2017;45:146–52. doi: 10.5152/TJAR.2017.51423. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Schotland HM, Jeffe DB. Development of the obstructive sleep apnea knowledge and attitudes (OSAKA) questionnaire. Sleep Med. 2003;4:443–50. doi: 10.1016/s1389-9457(03)00073-x. [DOI] [PubMed] [Google Scholar]
- 20.Uong EC, Jeffe DB, Gozal D, Arens R, Holbrook CR, Palmer J, et al. Development of a measure of knowledge and attitudes about obstructive sleep apnea in children (OSAKA-KIDS) Arch Pediatr Adolesc Med. 2005;159:181–6. doi: 10.1001/archpedi.159.2.181. [DOI] [PubMed] [Google Scholar]
- 21.Goyal A, Aswin P, Pakhare AP. Poor knowledge and attitude regarding obstructive sleep apnea (OSA) among medical students in India: A call for MBBS curriculum change. Sleep Vigil. 2018;2:45–50. [Google Scholar]
- 22.Chérrez-Ojeda I, Calderón JC, Fernández García A, Jeffe DB, Santoro I, Vanegas E, et al. Obstructive sleep apnea knowledge and attitudes among recent medical graduates training in Ecuador. Multidiscip Respir Med. 2018;13:5. doi: 10.1186/s40248-018-0117-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Ozoh OB, Iwuala SO, Desalu OO, Ojo OO, Okubadejo NU. An assessment of the knowledge and attitudes of graduating medical students in Lagos, Nigeria, regarding obstructive sleep apnea. Ann Am Thorac Soc. 2015;12:1358–63. doi: 10.1513/AnnalsATS.201412-561OC. [DOI] [PubMed] [Google Scholar]
- 24.Medical Counsil of India. Competency based Undergraduate Curriculum for the Indian Medical Graduate. Medical Counsil of India. 2018 [Google Scholar]
- 25.Medical Counsil of India. Competency based Undergraduate Curriculum for the Indian Medical Graduate. New Delhi: 2018. [Google Scholar]
- 26.Medical Council of India. Competency based Undergraduate curriculum for the Indian Medical Graduate. 2018;2:1–235. [Google Scholar]
- 27.Ministry of Health and Family Welfare G of I. National Mental Health Survey of India, 2015-2016 Prevalence, Patterns and Outcomes. Bengaluru: Ministry of Health and Family Welfare, Government of India; 2016. [Google Scholar]
- 28.Stevens MS. Restless legs syndrome/Willis-Ekbom disease morbidity: Burden, quality of life, cardiovascular aspects, and sleep. Sleep Med Clin. 2015;10:369. doi: 10.1016/j.jsmc.2015.05.017. [DOI] [PubMed] [Google Scholar]
- 29.Sedky K, Bennett DS, Carvalho KS. Attention deficit hyperactivity disorder and sleep disordered breathing in pediatric populations: A meta-analysis. Sleep Med Rev. 2014;18:349–56. doi: 10.1016/j.smrv.2013.12.003. [DOI] [PubMed] [Google Scholar]
- 30.National Academy of Medical Sciences (India) K. Singh K, Sharma B, Misra S, Bajaj JS. Published by K.N. Rao for the National Academy of Medical Sciences (India); 2015. Annals of the National Academy of Medical Sciences (India) [Google Scholar]
- 31.Mindell JA, Bartle A, Wahab NA, Ahn Y, Ramamurthy MB, Huong HT, et al. Sleep education in medical school curriculum: A glimpse across countries. Sleep Med. 2011;12:928–31. doi: 10.1016/j.sleep.2011.07.001. [DOI] [PubMed] [Google Scholar]
- 32.Mindell JA, Bartle A, Ahn Y, Ramamurthy MB, Huong HT, Kohyama J, et al. Sleep education in pediatric residency programs: A cross-cultural look. BMC Res Notes. 2013;6:130. doi: 10.1186/1756-0500-6-130. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Angriman M, Cortese S, Bruni O. Somatic and neuropsychiatric comorbidities in pediatric restless legs syndrome: A systematic review of the literature. Sleep Med Rev. 2017;34:34–45. doi: 10.1016/j.smrv.2016.06.008. [DOI] [PubMed] [Google Scholar]
- 34.Baldi I, Gulati A, Lorenzoni G, Natarajan K, Ballali S, Kameswaran M, et al. Public health implications of obstructive sleep apnea burden. Indian J Pediatr. 2014;81(Suppl 1):55–62. doi: 10.1007/s12098-014-1539-8. [DOI] [PubMed] [Google Scholar]
- 35.Agrawal S, Gupta R, Lahan V, Mustafa G, Kaur U. Prevalence of obstructive sleep apnea in surgical patients presenting to a tertiary care teaching hospital in India: A preliminary study. Saudi J Anaesth. 2013;7:155–9. doi: 10.4103/1658-354X.114072. [DOI] [PMC free article] [PubMed] [Google Scholar]