Couples-based interventions to promote PAP adherence among older adults: a qualitative study of patients, partners, and providers

Abstract

Study Objectives:

Bed partners play a critical role in the treatment of obstructive sleep apnea and are affected by the treatment (or lack thereof) of their partner’s obstructive sleep apnea, but few studies have included partners formally in treatment. In this qualitative study, we examine key stakeholder perspectives (patient, bedpartner, and sleep medicine provider) to inform the development of a novel, couples-based intervention to promote adherence to positive airway pressure (PAP) and sleep health among older adult couples.

Methods:

We conducted 3 focus group discussions with patients with obstructive sleep apnea/using PAP and their partners and 3 focus group discussions with sleep medicine providers. A standard interview guide was used to gather stakeholder input: (1) to understand interdependence of sleep among couples with sleep apnea; (2) to understand collaborative strategies that couples are currently using to address their sleep health challenges, including their perceptions of what is helpful vs not helpful; and (3) feasibility of the intervention design and delivery. Interviews were transcribed and thematically analyzed.

Results:

Participants (n = 25) included 9 patients, 7 partners, and 9 providers. Analysis of the discussion identified themes within the 3 topics addressed in the focus group discussions: (1) interdependence of sleep health among couples, (2) collaboration and other dyadic strategies for increasing PAP use, and (3) facilitators and barriers to a couples-based PAP adherence intervention. Results of the focus group discussions provided new insights into collaborative strategies that could be used to enhance the sleep health of both patients and partners. Patient/partners reported that a couples-based treatment could reduce common frustrations experienced by new PAP users, thereby benefiting their relationship. However, barriers to couples-based treatment included patients and partners feeling overwhelmed and reluctance to discuss intimacy. Providers recognized the benefits of involving partners but reported concern about exacerbating conflict in the couple.

Conclusions:

Results indicate that couples and providers are enthusiastic about couples-based treatment that addresses their individual and dyadic sleep health challenges and identified important barriers that will need to be addressed to enhance uptake by clinicians and participation/retention of couples.

Citation:

Baron KG, Troxel WM, Galloway S, et al. Couples-based interventions to promote PAP adherence among older adults: a qualitative study of patients, partners, and providers. J Clin Sleep Med. 2022;18(11):2627–2634.

BRIEF SUMMARY

Current Knowledge/Study Rationale: More than half of patients with obstructive sleep apnea have poor adherence to positive airway pressure, and it is well-established that relationship quality and partner support are strong predictors of better adherence.

Study Impact: The objective of this study is to advance the understanding of collaborative strategies in positive airway pressure treatment and seek patient, partners, and sleep medicine provider input to develop and refine a novel transdiagnostic, couples-based intervention to promote positive airway pressure adherence and improve sleep health among older couples. Results will inform the feasibility and acceptability of our novel intervention.

INTRODUCTION

Obstructive sleep apnea (OSA) affects 30%–50% of older adults^1,2 and increases risk for the major causes of morbidity and mortality, including cardiovascular disease,³ stroke,^4,5 and Alzheimer’s disease and related dementias.^6,7 The consequences of OSA, including fragmented sleep, reduced quality of life, and increased relationship conflict, affect both the patient and partner.^8,9 Therefore, the health consequences of OSA¹⁰ extend beyond the patient and affect the partner’s health as well.

The first-line treatment for OSA, positive airway pressure (PAP), improves both patient and bed partner sleep¹¹; however, up to 80% of patients are nonadherent.^12–14 Our preliminary work and others’ has demonstrated that partner support strongly enhances PAP adherence, whereas relationship conflict may reduce adherence.^15,16 For example, our work has shown that collaborative support (eg, helping with the PAP machine) strongly predicted greater adherence, whereas pressure (eg, nagging) to use continuous PAP (CPAP)¹⁶ and relationship conflict predicted lower adherence.¹⁵ Furthermore, spouses/partners are often primary motivators to seek diagnosis and treatment for OSA, whereas 50% of OSA patients reported they would not use PAP if it disrupted their partners’ sleep.¹⁷ Thus, integrating the bedpartner into OSA treatment may have substantial benefits for treatment adherence and both patient and partner outcomes, such as health, relationship quality, and quality of life.

To date, however, only 1 small pilot investigation¹⁸ has incorporated a couples’ perspective into a PAP adherence intervention, specifically by examining the feasibility of a couples’ education and support intervention compared to a patient-oriented education and usual care groups interventions among a total of 30 couples (10 per group). Results demonstrated improvements in patient PAP adherence as well as moderate to large improvements in sleep quality and reductions in daytime sleepiness in patients and partners in the couples’ group; however, only 6 of 10 couples randomized to this condition completed the intervention, highlighting the challenge of having both members of the couple attend in-person sessions. Another potential limitation to prior couples-based treatment for OSA and PAP adherence is that the intervention is focused on 1 person and 1 disorder, assuming the partners’ sleep problems would resolve when the patient began using PAP. However, especially among older couples, both patients and partners are likely to face a host of sleep health challenges beyond OSA, including insomnia/poor sleep quality, circadian disruptions (such as phase advances or irregular sleep/wake schedules), and high prevalence of other age-related comorbidities (eg, pain) that may increase the risk of sleep disruption and poor daytime functioning in both members of the couple.^11,19 In turn, these more broadly defined sleep health challenges,²⁰ encompassing OSA symptoms, as well as insomnia symptoms, circadian disruption, and daytime symptoms (eg, fatigue, sleepiness) can increase the risk for negative health sequelae in both partners, including cardiometabolic disorders, cognitive decline, poor relationship functioning, and reduced quality of life.^21–25

Although most sleep interventions in general, and specifically all the limited research on couples-based OSA interventions, have taken a disorder-specific approach (ie, focusing on the causes, maintenance, and treatment of a single disorder viewed in isolation), recent research by Harvey and colleagues’²⁶ demonstrates the utility of transdiagnostic approaches to sleep interventions. Specifically, the transdiagnostic framework explicitly recognizes that sleep symptoms and disorders, rarely exist in isolation and that overlap of sleep challenges with sleep disorders presents an opportunity to target shared mechanisms underlying common sleep health problems in older adults. Moreover, as articulated by Buysse, sleep health is “best understood in the context of individual, social, and environmental demands…”²⁰ We contend that the sleep health of the couple and PAP adherence is best supported by a transdiagnostic approach that recognizes the importance of supporting the multiple dimensions of sleep health of both partners in the dyad. Drawing from couples-based theory and intervention research,^9,27 we have hypothesized that a “we”- focused approach that leverages communication and collaboration among partners has the potential to benefit both partners’ sleep health and may promote better outcomes overall for both partners.

Based on this premise, our team is utilizing an iterative process of developing and evaluating a novel intervention, called We-PAP, the first couples-based sleep health intervention that focuses on improving PAP adherence and improving sleep health for the couple. Consistent with recommendations for developing effective and empirically grounded treatments, a critical step is to gain phenomenological perspectives from key stakeholders.²⁸ After developing our initial theory and formatting an outline of the potential intervention, our next step is to discuss the intervention with stakeholders to finalize the intervention before moving on to a field trial. Therefore, the goal of this study is to present our qualitative results from discussions with stakeholders (ie, patients with OSA/PAP users, their partners, and sleep medicine providers) to inform our intervention development and enhance the feasibility of our pilot clinical trial. The goals of these interviews were 3-fold: (1) to evaluate stakeholder understanding of the treatment rationale; (2) to understand strategies that couples are currently using to address their sleep health challenges, including their perceptions of what is helpful vs not helpful; and (3) to assess feasibility of the treatment, including the format, number of sessions, and mode of delivery, given the characteristics of the study population (older adult couples). In turn, these perspectives were used to align our concepts and intervention protocol before moving on to a field trial and then a pilot, randomized clinical trial.

METHODS

Participants and procedure

The focus group discussions (FGDs) in this project were a part of a larger pilot development study (NCT04759157) for the We-PAP intervention. This study was approved by the University of Utah (IRB_00135927) and all participants were provided with a consent cover letter before enrolling in the FGD.

Patient FGDs

We completed 3 FGDs with patients and partners. Patients with OSA who are using PAP and their partners, age 50 years and above were recruited from the University of Utah Sleep Wake Center from PAP follow-up appointments. Although the intervention focuses on new PAP users, we recruited existing PAP users to obtain feedback on their early experiences (average 8 years of PAP use, range 2–15 years). Partner use of PAP was not exclusionary (n = 2 partners were also PAP users). Couples (patient and partner dyads) were invited to participate in the focus group together; however, 2 patients attended without their partners due to last minute scheduling conflicts.

Provider FGDs

Providers were recruited from the Sleep Center staff and other local sleep centers. We recruited a range of sleep professionals, including physicians (pulmonary, psychiatry, neurology), advanced practice nurses, physician’s assistants, and sleep technicians.

Procedures

FGDs were scheduled for 60 minutes and held over Zoom using a standardized interview guide. The facilitators (KB and WMT) were both clinical psychologists with training in qualitative interviews. The groups also had a note taker (GD) and a technical support person (AG). The discussions followed a semistructured format. First, we began by opening the session by seeking perspectives on the overall treatment rationale, which focused on the interdependence of sleep, including the impact of OSA and PAP on the sleep health of the couple and their adjustment to starting PAP therapy. Next, we discussed couples’ interest in and feasibility of We-PAP, a couples-based sleep health intervention for patients beginning PAP treatment and their partners. To guide the discussion, which was facilitated by a series of open-ended questions, we presented a brief (4 slides total) overview of the intervention development in progress that included (1) the concept of shared sleep in couples and goals of the treatment to elicit stakeholder input on their understanding and “buy-in” for treatment rationale) and (2) program logistics (number of sessions, remote delivery, payment) and draft content for each of the sessions to elicit stakeholder feedback on the feasibility and potential uptake of the study. Following the discussion, participants completed a brief demographics survey via RedCap. Participants were each sent a $30 electronic gift card for participating. The interview guide is included in Table 1.

Table 1.

Structured interview guide.

1. Introduction
a. Ground rules (confidentiality, equal speaking time)
b. Using technology (eg, muting and unmuting)
2. Couples’ experience with OSA and using PAP
a. Effects of OSA and PAP on the relationship
b. How partners are involved in PAP
3. Intervention description (concepts, session format, session content, 4-slide overview)
a. Concept of shared sleep
b. Format of the sessions (Zoom vs in person), payment
c. Content of each session
4. Recruitment
a. Strategies for recruiting couples
b. Recruiting before they receive PAP at home
5. Summary and wrap-up
a. Completing the postgroup survey
b. Processing payments

OSA = obstructive sleep apnea, PAP = positive airway pressure.

Analysis

Focus group discussions were recorded in Zoom and audio files were transcribed verbatim (Trint audio transcription software, London, UK). The recording failed from 1 of the focus groups; therefore, we used session notes to identify themes from that session. Transcripts were uploaded into Dedoose software for coding and analysis (SocioCultural Research Consultants LLC, Los Angeles, CA). Data analysis was conducted using methods of applied thematic analysis,²⁹ which is a set of procedures designed to identify and examine themes from textual data in a way that is transparent, reproducible, and credible. Thematic analysis was conducted in two stages: a deductive stage and an inductive stage.³⁰ The deductive stage followed Crabtree and Miller’s³¹ methods of structured, deductive coding. The first and senior authors (KB and WT) read the transcripts and coded text for 3 broad domains: interdependence of sleep and daytime functioning, spousal involvement in PAP, and facilitators and barriers to couples-based treatment. In the inductive stage, the team reviewed the coded text to reach consensus on emerging themes in each domain. The coders (SK and SG) and the first author (KB) met to review the emerging themes and to create a detailed codebook that defined each theme. The coders then applied the codes to the transcripts. Although thematic saturation³² was reached after coding 4 transcripts, we proceeded to code all available transcripts. In the final step, first and senior authors (KB and WT) reviewed and edited the final coding structure and themes to ensure that each code represented a distinct theme of the discussions.

RESULTS

Participant characteristics are listed in Table 2. Participants included a total of 25 individuals: 9 patients with OSA, 7 partners, 3 polysomnography technicians, 1 advanced practice nurse, and 5 sleep medicine physicians (pulmonary, psychiatry and neurology). In the patient and partner groups, mean age was 68 years (range 51 to 87 years), 50% of them were female, and they were married an average of 39 years (range 20–55 years). Themes were identified in 3 major domains: (1) interdependence of sleep health among couples, (2) collaboration and other dyadic strategies for increasing PAP use, and (3) facilitators and barriers to a couples-based PAP adherence intervention.

Table 2.

Participant characteristics.

	Patients (n = 9)	Partners (n = 7)	Providers (n = 9)
Age, years	68.1 (11.8)	67.1 (7.3)
Sex	5 females; 4 males	3 females; 4 males	4 females; 5 males
Ethnicity	8 White; 1 more than 1 race	7 White
Marriage length, years	38.3 (13.0)	37.1 (2.5)
PAP h/night, reported	7.6 (1.1)

Values are presented as n or mean (standard deviation).

Domain 1: Interdependence of sleep health among couples

In this domain, 2 themes emerged: sleep health challenges in the couple due to OSA and influence of PAP on the couples’ sleep, daytime function, relationships, and mood. Emerging themes from these topics helped us better understand how the couples’ sleep affected each other and their relationships to identify relevant targets for couples-based intervention.

Sleep health challenges in the couple due to OSA

Consistent with our transdiagnostic approach, couples reported a variety of sleep health challenges, including vigilance and anxiety at night that contributed to insomnia symptoms in both partners.

“If they’re sleeping poorly, that makes you sleep poorly, too. So, you know, you’re just waiting for it. If you wake up and you hear them and they’re not breathing, you’re just waiting for that big gulp of air, you know? And so that’s it kind of ruins everybody’s sleep.” –Partner, female

Patients also described trouble sleeping due to concern that their snoring or the PAP machine might disturb their partners’ sleep. There was considerable discussion among patients and partners about the decision to sleep in separate beds or bedrooms to support both of their sleep. Some couples were satisfied with sleeping separately and other couples desired to return to sharing a bed or bedroom. Providers discussed how a partner’s sleep disruption due to snoring is a common reason that patients report for seeking treatment and observed “takes a toll on them as a couple and their marriage”, as it becomes a source of resentment and conflict.

Effects of PAP on the couples’ sleep, daytime function, relationships, and mood

Overall, patients and partners reported sleeping better after starting PAP, largely due to cessation of the patient’s snoring. Several of the couples and some of the providers reported that when the partner observed the patients’ improvements after starting PAP, it made the partner also seek an evaluation for OSA and began using PAP themselves.

“She was very happy [when I started using PAP] and in fact, we had her do a sleep study and then she started CPAP too, so we were both happy.” –Patient, male

Couples discussed how using PAP improves their mood (“less grouchy”) and how they hoped it would lead to a “longer, better life”. These findings demonstrate that patient and partner motivations and perceived benefits of using PAP are deeply embedded within the context of the relationship, consistent with the rationale for addressing sleep as a shared behavior.

“…it’s most often that in my experience, it’s the wife urging the man to come in and be evaluated. And sometimes it’s just a response to sensing life’s challenges are overwhelming the man and the hope that perhaps in understanding the sleep issue, that there might be a path back to functioning for him” –Provider, male

Partners also discussed their belief that treating OSA improved the patient’s health.

“Yeah, so I’m happy that he’s keeping his brain cells and being able to stay active and alert.” – Partner, male

Providers reported discussing improvements with couples as a “selling point” to partners about the benefits they will observe if the patients use PAP (“you’ll recharge your battery”, “you’ll get your spouse back”).

Couples also discussed how the PAP negatively impacted the partners’ sleep at times, including noise, leaking, and the partner waking to help adjust the machine. However, the providers rarely discussed this aspect of couples’ adjustment to PAP. This gap between patient experience and provider demonstrates an area that could be specifically addressed in a couples-based program.

“This is the most frustrating part for me is when it has a leak and it’s making a whistling noise or a rushing noise with air blowing out, you’re asleep. You can’t hear it. I’m there awake, listening to it, hoping that it will stop. Not wanting to wake you up.” –Patient, male

Domain 2: Collaboration and other dyadic strategies

Couples discussed how they worked together to adjust to PAP and the ways partners supported PAP usage. Providers discussed how they involve the partner in education and training. Three themes emerged in this domain: overcoming problems adjusting to PAP together, emotional/instrumental support, and pressure to diagnose OSA. The discussions in this area provided concrete examples of collaborative strategies that helped couples adjust to PAP and other ways they supported each other.

Overcoming problems together

Couples discussed their process of overcoming initial problems together when the patient was beginning PAP treatment. They reported ways they “shared the burden”, including establishing routines, taking on roles (adjusting the mask or filling the water), and establishing new strategies to wind down together. The example below demonstrates how a patient and partner communicated a plan for how to negotiate falling asleep without the mask on. In a couples-based treatment, we would work with couples to negotiate a plan that could enhance adherence to PAP (eg, a reminder to put on the mask) rather than leaving the room.

“I think what would be helpful is to decide as a partner ahead of time … he would say to me, or I would say to him “what do you want me to do if I see that forgot your mask, but you’re asleep? You want me to wake you up or do you want me to just let you sleep if it’s making noise? You want me to poke you in the ribs and make you roll over, or do you want me to just go in the other room?” –Partner, female

One topic that was discussed by several couples was establishing a way of putting away the machine each morning, so it feels less “medical” in their bedroom.

“… we just got a dresser that was big enough and we put it [PAP] in the bottom drawer. And so then he just opens the door enough for the hose in the mask to come out and, you know, he can access it that way. And then in the morning, we just closed the drawer and it’s all put away. And that kind of takes the kind of the medical feel of it away a little bit so that your bedroom doesn’t look like you’ve got this machine and the hoses and all that. This is a nighttime thing and it’s not something we’re looking at all the time, too.” –Patient, female

Providers discussed the techniques they use with couples to enhance intimacy and reduce self-consciousness about wearing the mask, such as suggesting patients wait until they are sleepy to put on the PAP.

Emotional and instrumental support

Another important area for collaboration was communicating support, for both PAP adherence and sleep health in the partner. We identified both emotional support (acceptance, empathy) and instrumental support (ie, offering assistance in a tangible or physical way). More subtle types of support were also viewed as important to patients, such as an appreciation for feeling supported or accepted by their partners (eg, did not make fun of the PAP). Patients also reported that one role of a couples-based treatment could be increasing empathy in the partner for what the patient is going through while adjusting to PAP, while also recognizing that the adjustment can also affect the bedpartners’ sleep quality. The following patient provided an example of a subtle expression of support:

“I think from my point of view, the fact that he never complained about my CPAP, in other words, he didn’t say, oh, gosh, that’s awful or anything like that. It’s just an acceptance. And it makes me feel like, OK, so I look like I’m an astronaut or something wearing this big thing on my face…it’s OK because he’s never made me feel bad about it.” –Patient, female

Patients and partners reported many tangible ways that partners provide instrumental support, including being the “IT [internet technology] person” to help with the machine’s connection to the clinic, purchasing distilled water and filling the humidification chamber, keeping supplies organized, helping wake the patient if they forgot to put it on, checking that the machine is plugged in. Providers discussed their efforts in engaging the partner by giving them suggestions, such as reminding the patient to put on their mask before falling asleep or nudging them if the mask needs adjustment in the night.

Domain 3: Facilitators and barriers to couples-based treatment

In this domain, we identified factors that FGD members felt would make it more or less feasible or useful to participate in couples-based treatment for PAP adherence. In terms of facilitators, patients reported that couples-based treatment would likely “reduce frustration” since both the patient and partner could be trained on the PAP machine. They also reported the treatment could help improve communication and empathy among the couple while coping with the frustration of getting used to a new treatment. Finally, couples reported that they would find it valuable to have a program that advocated for the patient and helped them navigate early treatment challenges (eg, mask changes). Patients and partners liked the online/telehealth format and thought participating via Zoom would reduce burden of participating in the intervention.

“I think I should have had better directions on how the equipment worked and maybe with my husband there at the same time. Because it’s a little overwhelming at the beginning, but it wasn’t done that way.” –Partner, female

Providers felt that the We-PAP treatment would have an advantage over standard of care for OSA because it would allow for more time to explain the treatment to the couple. They liked the team approach (“it’s a we-thing”) and suggested that we promote the program by focusing on improving sleep and energy for the couple, not just about using PAP.

“…telling patients that there’s a lot of details that come up with CPAP and providers are pressed for time. We’ll have the time to answer your questions…presented to the patient says, hey, we’re here to solve problems and issues as they come up, if they come up. So the couples don’t feel like they’re signing up for a class…” –Provider, male

Patients reported couples may have difficulty participating in a couples’ intervention due to time constrains and having “information overload” when starting a new treatment. They also expressed concerns that a couples-based intervention would ask them to discuss intimacy or their sex lives. They felt that discussing intimacy, particularly in a group setting, would be uncomfortable.

“I think some people might be a little bit afraid that there’s going to be a lot of questions about intimacy, if you will. And I’m much more willing to talk to you about my sleep habits than I am about my sex habits, if you will. And so if they knew that it was really mostly just about sleep, that’s one aspect that might help” –Patient, female

Providers discussed their concerns that a couples-based treatment could amplify existing conflict within the couple.

“I just wonder what their dynamics are beforehand and how that would affect it, like if they already have a contentious relationship…. you hope that they’re supportive to each other, but I think there might be that caveat, if there’s some background history of not being supportive.” –Provider, female

DISCUSSION

The current study provides new insights into the shared experiences of couples with OSA and is an important preliminary step in gathering the information needed in the development of We-PAP, a novel, couples-based intervention for PAP adherence and sleep health among older couples. The goal of this study was to obtain perspectives from couples and sleep medicine providers that would guide our intervention development by involving key stakeholders, to obtain feedback on the concepts, content, and delivery of the intervention. We began these FGD with a concept and general outline for how our intervention could be delivered and then engaged in the important step of stakeholder feedback. Although most adults share a bed with a bedpartner,^9,33 the demonstrated impact of OSA on sleep, relationship quality, and health of both partners,^11,34,35 and the recognized importance of bedpartners in both the diagnosis and treatment of OSA,¹⁷ there continues to be limited efforts to systematically involve partners in OSA treatment. The emerging themes in our FGDs extend prior qualitative studies in couples by (1) increasing our understanding of ways the transdiagnostic framework could address sleep problems in the couples; (2) increasing the depth of couples’ collaborative strategies and communication, which we will leverage in our intervention to improve PAP and sleep health; (3) including provider perspectives, key stakeholders who have not been included in prior qualitative interviews about couples-based treatment; and (4) identifying ways to address the challenges in enrolling and retaining couples with OSA.

The FGDs suggest that the concept of interdependent sleep resonated with couples and providers,^9,36 in that couples’ sleep is dynamic and interdependent and also depends on the context of the relationship, including the level of conflict or support in the relationship.³⁷ In terms of application to PAP use, results suggest that enhancing dyadic sleep and improving communication is an important aspect of improving PAP use. The disruptions in sleep among couples with untreated OSA may have implications for their relationship functioning and wellbeing as a couple. Therefore, a treatment that specifically addresses the dyad may be more successful at increasing adherence and improving sleep for both patient and partners. The importance of involving partners in PAP treatment was recognized by the patient/partner groups and providers, which suggests that there is substantial support for pursuing this type of treatment among key stakeholders.

Our results support and extend results of 2 previous qualitative studies of couples and CPAP by focusing more specifically on the collaborative strategies used by couples to support each other’s sleep.^38,39 The format of our groups (multiple couples per group) allowed us to obtain more detailed information about how couples’ relationships have been effected by OSA and allowed for further discussion of potential shared mechanisms underlying other sleep health challenges that could be address in a transdiagnostic framework. For example, vigilance or hyperarousal is frequently reported among partners of patients with OSA as well as patients themselves. Partners in our study described how their vigilance continued even when the patient is using PAP; for example, in monitoring whether the patient unknowingly removes the mask at night. Patients also acknowledged experiencing trouble sleeping due to concerns about how their snoring or the noises from the machine might interfered with their bedpartners’ sleep. Therefore, additional techniques such as those found in cognitive behavioral therapy for insomnia may be useful in this population to reduce frustration (cognitive techniques) and conditioning, such as stimulus control. Furthermore, encouraging both partners to have patience and to expect some level of an adjustment period to the new PAP machine may help to reduce anxiety-related sleep disruptions. Second, our interviews allowed us to have detailed discussions of couples’ strategies to adjust to PAP, such as how they show support, communicate during challenges, and established new routines and responsibilities in managing the new treatment. A common theme between our study and these 2 prior studies was the impact of PAP treatment on intimacy and concerns over the appearance of the mask in front of their spouse. In discussing these topics in our FGD, we were able to gather information from patients about ways to sensitively integrate these topics into our intervention.

Although there was coherence in the themes and issues identified by each stakeholder group, some notable discrepancies between the groups were also particularly salient. For example, couples frequently discussed how noise or blowing air from PAP was bothersome and may lead to the partner sleeping in a separate room. However, this topic was not identified in the provider groups and may be an example of an area that could be covered in a treatment that addressed the sleep of both the patient and partner. In addition, only providers expressed a concern that a couples-based treatment would have the potential for such an intervention to “stir up” or exacerbate existing tensions within a couple. This concern is akin to a primary barrier to screening for suicidality in primary care practices—that such assessment could “induce” or increase the risk of suicidality in patients.⁴⁰ Interestingly, as with our findings, this concern regarding suicidality assessment is more often expressed by providers than patients and is not supported by the available evidence.⁴¹ Nevertheless, given the limited time for medical visits as well as the lack of training for medical providers in couples’ therapy or relationship dynamics, it is understandable that they may be hesitant to incorporate bedpartners, particularly if there is discord in the relationship. Notwithstanding these concerns, couples with existing relationship discord may stand to benefit even more from a couples-based treatment by improving sleep and communication skills in both partners. For example, in the context of a couples-based intervention with cardiovascular disease, the intervention demonstrated greater benefits among couples with higher levels of relationship distress compared to those with lower levels of distress, likely because the distressed couples had more opportunity to learn from healthy collaboration and communication strategies.⁴²

In addition to gathering detail about the acceptability of our intervention, we also used the FGDs to obtain specific feedback on the content and format of our couples-based sleep health intervention: We-PAP. Based on the feedback from patients, partners, and providers, we made several modifications to our first draft of the intervention, which is consistent with treatment development recommendations.²⁸ First, patients and partners reported they wanted the first session to focus more on the mechanics of using PAP, including increased attention to the problems and solutions that patients and partners experience in the first few weeks. All stakeholders suggested that training the partner on the machine set-up and troubleshooting is critical and that providers (and also durable medical equipment suppliers) often do not have enough time to go over these details together with the couple. Second, we learned new strategies from couples about how they changed their bedtime routines to incorporate PAP. Therefore, we added a section of the intervention to focus on developing wind-down routines together and incorporating PAP as the last step in that routine to improve connectedness within the couple and reduce self-consciousness for the individual with OSA. Last, the focus group discussions highlighted the need for a nuanced discussion of sex, intimacy, and PAP. Although some couples wanted to discuss this aspect of their relationship, others felt uncomfortable. Therefore, we identified areas in our sessions where we could open the topic of intimacy broadly, such as discussing emotional and physical connectedness, and allowing for discussion of intimacy based on the couples’ comfort level and interest. In respect to the format of the intervention, we also streamlined the sessions to focus each session on a central theme, to avoid “information overload” and utilize the role of the coach in troubleshooting early issues with the treatment.

Our results are potentially limited by selection bias, as this was a convenience sample. Patients with higher relationship quality or better PAP use may be more likely to participate in a couples-based FGD about their experience using the treatment. In addition, conducting the groups over Zoom may have enhanced accessibility for some couples (reducing travel time to clinic), but it may also have interfered with building rapport among the group. We carefully considered the format of investigation (patient and partner groups separately, couple’s interviews). We chose focus groups of couples because this was a cost and time-effective method to obtain differing perspectives and allowed couples to compare their experiences. Especially, because we were talking with established PAP users and asking their perspectives for what would have been helpful when they were starting PAP, we felt this interactive approach would be useful. There were some limitations, however, to discussing in a group setting. For example, couples indicated some topics (eg, intimacy) would have been more comfortable to discuss in couple’s interviews rather than in an FGD. In addition, it is possible that some partners may have preferred to participate in the interview alone because they did not want to say something that could be construed as criticism to the patient. On the other hand, the benefit of interviewing the patient and partner together is that it allowed them to interact and discuss their experiences with PAP together and focus on their shared experience.

CONCLUSIONS

The results of these FGDs highlight the importance of incorporating partners in PAP use and suggest that a couples-based approach to promoting PAP adherence and sleep health of the couple will be acceptable in this population and may be an effective strategy to improve both patient and partner outcomes. These perspectives have been incorporated into our novel, couples-based PAP and sleep health intervention, We-PAP, which we are currently in the process of conducting in a randomized controlled pilot trial. More broadly, the results of this qualitative analysis have implications for OSA treatment in general, suggesting that current clinical care of OSA could benefit from integrating bed partners into the treatment using a couples-based framework.

ABBREVIATIONS

OSA

obstructive sleep apnea

PAP

positive airway pressure

CPAP

continuous positive airway pressure

FGD

focus group discussions

DISCLOSURE STATEMENT

All authors have seen and approved this manuscript. Work for this study was performed at the University of Utah. This study was funded by National Institute on Aging Grant 1R21AG067183. The research reported in this publication was supported (in part or in full) by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR002538. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors have the following conflicts of interest to disclose: K.B. is a consultant for the National Sleep Foundation, W.M.T. is a scientific advisor for Feelmore Labs, OneCare Media, and National Sleep Foundation. She is author of the book Sharing the Covers: Every Couple’s Guide to Better Sleep. K.S. is on the Advisory board for ResMed and Merck Inc. He is also the cofounder of Hypnoscure LLC through the University of Utah Technology commercialization office software designed for population management of sleep apnea.