Behavioral Sleep Medicine, 8:105112, 2010 Copyright Taylor & Francis Group, LLC ISSN: 1540-2002 print/1540-2010 online

e DOI: 10.1080/15402001003622859

Personalized Feedback to Improve CPAP Adherence in Obstructive Sleep Apnea

Kathryn A. Roecklein
Department of Psychology University of Pittsburgh

Julie A. Schumacher
Department of Psychiatry and Human Behavior University of Mississippi Medical Center

Jeanne M. Gabriele
G. V. Sonny Montgomery Veterans Affairs Medical Center

Colleen Fagan
Department of Psychology University of Texas Southwestern Medical Center

Alp Sinan Baran and Allen C. Richert

Department of Psychiatry and Human Behavior; and Department of Internal Medicine University of Mississippi Medical Center

Obstructive sleep apnea (OSA) is effectively treated with continuous positive airway pressure (CPAP). Low rates of CPAP adherence led to the development of a personalized feedback intervention requiring minimal provider burden. In a comparison of the intervention to standard information, group differences failed to reach signicance. Explanations for the ndings include low power, that machines were not provided, and an atypical sample. Effect sizes were medium to large at 2 weeks, suggesting that sufciently powered studies may be warranted.

Obstructive sleep apnea (OSA) involves obstructed breathing during sleep, decrements in blood oxygen levels, daytime sleepiness, and risk of car accidents (Cartwright, 2003; Findley et al., 1995; Pack et al., 1995). Consequences include hypertension, cognitive and mood changes,
Correspondence should be addressed to Kathryn A. Roecklein, Department of Psychology, University of Pittsburgh, 210 South Bouquet St., Pittsburgh, PA 15260. E-mail: kroeck@pitt.edu

105

106

ROECKLEIN ET AL.

and increased mortality (Bassiri & Guilleminault, 2000; Meslier et al., 1998; Sigurdson & Ayas, 2007). OSA may be more severe in African Americans (Jean-Louis et al., 2008), so investigation of racial disparities is imperative. Although continuous positive airway pressure (CPAP) is effective, 20% of users stop use within 1 year (Reeves-Hoche, Meck, & Zwillich, 1994), and only 46% use CPAP for at least 4 hr nightly (Kribbs et al., 1993). Blood pressure is correlated with CPAP use (Nieto et al., 2000), and sleepiness is not resolved after low levels of use (3.7 hr 0.4 hr), so disuse and low use are both targets for intervention (Engleman, Martin, Deary, & Douglas, 1994). The amount of provider time and unique skills needed for effective adherence interventions may limit their adoption. CPAPMotivation Enhancement (CPAPME) therapy, consisting of two 45-min sessions and a 15-min follow-up call, led to an increase of CPAP use in a pilot study (Aloia, Arnedt, Riggs, Hecht, & Borrelli, 2004; Aloia et al., 2007) and lower rates of CPAP discontinuation compared to standard care (Aloia et al., 2007). Supplying patients with a written personalized feedback report is an intervention, such as CPAPME, based on theories of behavior change with demonstrated predictive validity in CPAP adherence (Aloia, Arnedt, Stepnowsky, Hecht, & Borrelli, 2005; Stepnowsky, Marler, & Ancoli-Israel, 2002) that requires minimal provider time. Similar approaches led to signicant improvements in substance use (e.g., Larimer et al., 2007; Smeets, Kremers, de Vries, & Brug, 2007). This study tests whether written feedback can increase CPAP use.

METHOD Consecutive clinic patients were enrolled after receiving their OSA diagnosis and CPAP prescription. Participants were randomly assigned to feedback or standard information groups. Physicians were blind to study participation, and participants were blind to their study condition. Participants were not provided machines in the study but obtained machines naturalistically, most commonly through insurance.

Participants Individuals aged 18 to 65 were diagnosed by polysomnography (PSG; overnight in lab, EEG, chin electromyogram, electrooccuograms, airow with nasal pressure transducer, electrocardiogram, pulse oximetry, and anterior tibialis electromyogram), reported intent to use CPAP, and were nave CPAP users. Other sleep, psychiatric, or health problems were not exclusion criteria. All patients met current OSA criteria of experiencing daytime sleepiness, snoring loudly, breathing interruptions, or awakenings due to gasping or choking; and PSG ndings of 5 apneas, hypopneas, or respiratory effort-related arousals (RERAs) per hour of sleep as per Epstein et al. (2009). RERA was dened as any EEG arousal followed by evidence of upper airway resistance including any reduction in airow, snoring, or thoracoabdominal paradox. We dened the ApneaHypopnea Index (AHI) as apneas C hypopneas of 10 s with at least a 3% SaO2 desaturation. The Respiratory Disturbance Index (RDI) includes the AHI and RERAs.

FEEDBACK TO IMPROVE CPAP ADHERENCE

107

Interventions The only difference between groups was the content of the written information provided for independent reading. Groups are not expected to differ in the amount or type of education that participants may have received from primary care or sleep physicians or CPAP providers. Controls received three brochures from the American Academy of Sleep Medicine (AASM) entitled, Obstructive Sleep Apnea and Snoring, Positive Airway Pressure Therapy for Sleep Apnea, and Obstructive Sleep Apnea. The feedback report mirrors the AASM information, plus personal OSA severity, and risks phrased to be consistent with the motivational approach (Miller & Rollnick, 2002). Personalized feedback included the following data before and after CPAP use: AHI, RDI, average and lowest level of blood oxygen, and self-reported daytime sleepiness. Information was tailored for OSA as outlined by Aloia et al. (2004) and compared to normative data. Health risks were conveyed as follows: Without CPAP I am __ times more likely to have a car accident, I am __% more likely to have high blood pressure, and I am __% more likely to have a high body weight. Data on weight and blood pressure were used to predict the risk of obesity and hypertension (Nieto et al., 2000). The odds of having a motor vehicle accident were predicted using the method of Aloia et al. (2004). Feedback emphasized discrepancies between risks with and without CPAP and conveyed empathy with barriers to using CPAP, ambivalence about CPAP, the difculties of behavior change, and promoted self-efcacy and personal responsibility for choosing to use CPAP.

Measures The Side Effects Questionnaire assesses side effects interfering with CPAP use (Kribbs et al., 1993). The Calgary Sleep Apnea Quality of Life Symptoms scale is sensitive to change across treatment (Flemons & Reimer, 1998). The CPAP/BiPAP Questionnaire assesses self-reported use (Ball & Banks, 2001). The Social Cognitive Theory (SCT; self-efcacy, outcome expectations, social support, readiness, and knowledge) and the Transtheoretical Model (TTM; process of change and decisional balance index) Questionnaire Modied for CPAP Use measures factors associated with adherence (Stepnowsky et al., 2002). The Epworth Sleepiness Scale assesses daytime sleepiness (Johns, 1991). Objective measures of use were recorded directly from CPAP displays. Total hours is the cumulative number of hours the CPAP machine ran while the mask was on the users airway (95% of machines detected breathing; Respironics Inc., Murrysville, PA). Sessions is the cumulative number of separate events of use (i.e., nightly sleep plus any naps), and average hours is total hours divided by sessions. Repeated-measures ANOVA was used to compare groups (feedback vs. control) over time (2 weeks and 3 months). Individuals who had not obtained machines (2 weeks: control, n D 5 and feedback, n D 2; 3 months: control, n D 2 and feedback n D 1) were recorded as having used CPAP for 0 hours per sessions. Individuals whose machines did not record use or who forgot to bring machines to the research session were treated as missing data (2 weeks: control, n D 1 and feedback, n D 0; 3 months: control, n D 2 and feedback n D 2). Groups did not differ in the rates of missing versus present data at 2 weeks, 2 .2; N D 27/ D 3:86, ns; or 3 months, 2 .2; N D 28/ D 0:86, ns.

108

ROECKLEIN ET AL.

RESULTS Participants were 14 in the feedback group and 16 in the control group, and each group lost 1 to follow up. The groups were not different on most demographic and severity measures (see Table 1). The feedback group had a higher rate of married participants, 2 .1; N D 30/ D 5:571, p < :05; but marital status was not a predictor of variance in analyses. Groups did not differ on self-efcacy, outcome expectations, social support, readiness, knowledge, or decisional balance at baseline. The average income was $10,000 less than the median U.S. income (U.S. Census, 2003). There was no difference in average daily use, F .1; 19/ D 0:00, p D :99 or total hours, F .1; 20/ D 0:15, p D :71; and Mauchlys test of sphericity indicated equal variances. Post hoc t tests are reported to aid in interpretation of null ndings (see Table 2), along with effect sizes favoring the intervention at 2 weeks (Cohen, 1988). Individuals in the feedback group reported using CPAP longer than controls, F .1; 22/ D 7:13, p < :05; but this self-report measure is vulnerable to recall bias, as some reported using CPAP for 4 months at the 3-month visit. Groups did not differ in rates of CPAP side effects, sleepiness, or symptoms. There was a main effect of time on symptoms due to the expected decrease in symptoms over time, F .1; 25/ D 15:49, p < :01. Neither total therapy hours nor average daily hours of CPAP use predicted values of symptoms, side effects, or sleepiness at 2 weeks or 3 months. Studies show that obese African Americans reporting sleepiness are more adherent to CPAP (Jean-Louis

TABLE 1 Demographic and OSA Severity Data at Baseline Between Groups Control Group Variable Age Women (%) Educationa Incomeb White (%) Married (%) AHI RDI RERA Average O2 % CPAPc Sleepinessd BMIe M 46.10 75.00 13.31 $35,333 37.50 25.00 45.82 58.38 12.56 91.05 13.29 11.25 42.18 SD 11.50 2.89 $12,508 42.38 46.14 11.29 4.40 4.12 4.15 7.61 M 46.60 64.30 13.31 $31,823 28.60 64.30 42.69 53.34 10.65 91.16 13.46 11.92 42.06 Feedback Group SD 11.30 3.68 $13,128 34.34 31.27 6.10 5.25 3.23 5.50 8.91 M 46.30 70.00 13.31 $33,695 33.30 43.00 44.36 56.03 11.67 91.10 13.37 11.55 42.12 Total Sample SD 11.20 3.21 $12,702 38.21 39.35 9.14 4.73 3.64 4.72 8.16 F/
2

p .909 .694 .997 .460 .709 .047 .825 .732 .576 .949 .903 .710 .889

0.013 0.408 0.000 0.561 0.268 5.571 0.05 0.12 0.32 0.004 0.015 0.141 0.181

Note. AHI D ApneaHypopnea Index; RDI D Respiratory Disturbance Index; RERA D respiratory effort-related arousal; CPAP D continuous positive airway pressure; BMI D body mass index. a Education in years. b Income expressed as median household income, estimated from ZIP code. c CPAP prescribed pressure at baseline, in H2 O cm of pressure. d Sleepiness was measured by the Epworth Sleepiness Scale administered at baseline. e BMI measured as kg/m2 .

FEEDBACK TO IMPROVE CPAP ADHERENCE

109

TABLE 2 Objective and Subjective Measures of CPAP Use at 2 Weeks and 3 Months
Feedback Group Variable M SD Control Group M SD t p M 95% CI a d 95% CI(d)b

Objective measures from CPAP machine Total hours Two weeks 45.12 35.61 20.10 26.06 2.04 .05 25.02 25.26 .80 Three months 254.37 191.11 189.11 188.99 0.84 .41 65.26 161.39 .34 Average hours Two weeks 4.58 2.82 2.40 2.69 2.01 .06 2.17 2.23 .79 Three months 2.35 2.23 1.97 2.24 0.40 .70 0.38 2.00 .17 Sessions (separate use events)c Two weeks 5.77 6.08 2.08 3.04 1.96 .06 3.70 3.89 .77 Three months 30.27 26.68 25.73 26.05 0.40 .69 4.54 23.45 .17 Self-reported variables from questionnaires Self-reported days using CPAP Two weeks 11.26 7.89 7.11 8.45 1.32 .20 4.15 6.50 .51 Three months 93.75 15.83 66.43 32.07 2.68 .01 27.32 21.05 1.05 Self-reported time using CPAP (%) Two weeks 61.93 39.79 45.41 46.77 0.98 .33 16.52 34.55 .38 Three months 63.53 30.79 62.11 35.72 0.11 .91 1.42 26.13 .04 Self-reported nights per week using CPAP Two weeks 5.00 2.91 3.46 3.41 1.24 .23 1.54 2.57 .48 Three months 5.67 2.10 4.50 2.71 1.22 .23 1.17 1.96 .47 Self-reported average use per night (hours) Two weeks 4.05 2.98 3.36 3.18 0.54 .59 0.69 2.66 .22 Three months 4.68 2.12 4.12 2.49 0.61 .55 0.56 1.89 .24 Self-reported hours of sleep per night (from the sleep questionnaire) Baseline 6.17 1.68 5.34 1.53 1.35 .19 0.82 1.26 .51 Three months 6.31 1.63 5.87 1.67 0.70 .49 0.44 1.29 .27

0.01 to 1.60 0.47 to 1.15 0.02 to 1.58 0.67 to 1.00 0.04 to 1.56 0.66 to 1.00

0.27 to 1.27 0.22 to 1.87 0.27 to 1.14 0.70 to 0.78 0.30 to 1.26 0.30 to 1.24 0.59 to 1.03 0.53 to 1.01

0.25 to 1.27 0.48 to 1.01

Note. CPAP D continuous positive airway pressure; CI D condence interval. a Mean difference plus or minus 95% CI of the mean difference. b The 95% CI for the effect size estimate, Cohens d: 95% CI(d) (Cohen, 1988). c Although the CPAP machine records the number of sessions, this may not be equivalent to days used if participants used the machine twice in 1 day (e.g., naps).

et al., 2008). However, our groups did not differ on BMI or sleepiness, and BMI was not associated with CPAP use at 2 weeks or 3 months. As a group, baseline SCT and TTM variables did not predict total therapy hours at 2 weeks or average therapy hours, but baseline knowledge was correlated with therapy hours ( D 8:02, SE D 3:36, p < :05) and average daily use at 2 weeks ( D 0:873, SE D 0:319, p < :05). Total hours at 2 weeks was signicantly associated with total hours at 3 months [r 2 D :454, adjusted r 2 D :393, F .2; 18/ D 7:485, p < :05], but among the readiness and motivation variables, only baseline readiness predicted total therapy hours at 3 months ( D 207:97, SE D 94:60, p < :05). Motivation and readiness variables could be a proxy for objective use if they are highly predictive (Aloia et al., 2005). However, only some baseline variables predicted use in our study, and there were no group effects for self-efcacy, outcome expectations, social support, the decisional balance index, or knowledge. There was a main effect of time on readiness (F .1; 25/ D 49:44, p < :05), reecting the expected increase in readiness as participants initiated CPAP. Income did not signicantly predict whether a person obtained a machine at 2 weeks, t.26/ D 1:75, p D 0:09, 95% CI(diff) $9,762 $11,459; d D 0:76; 95% CI.d / D 0:12 1:63 or 3 months, t.27/ D 0:91, p D 0:37, 95% CI(diff); $7,268

110

ROECKLEIN ET AL.

$16,478; d D 0:55; 95% CI.d / D 0:65 1:75, but these data indicate there may be a medium-to-large effect of income on machine acquisition. The rate of individuals who did not obtain machines did not differ between groups at 2 weeks, 2 .1; 27/ D 1:45, p D :23; or 3 months, 2 .1; 28/ D 0:232, p D :63.

CONCLUSION Differences in objective measures of CPAP use did not reach signicance at 2 weeks or 3 months, but data presented in Table 2 indicate that the likely magnitude of the effect at 2 weeks would be large (total hours: d D 0:80; average hours: d D 0:79; sessions: d D 0:77; Cohen, 1988). Feedback may encourage early CPAP use, and 2-week use predicted 3-month use in our study. An adequately powered study of at least 41 total participants could test if promoting early use has durable effects, as shown by previous studies (Budhiraja et al., 2007). We reported 0 hours or sessions for those who did not obtain machines, which may reect low motivation, low income, or a combination, as reected by 1 patient who borrowed a machine to save money but did not take it to the sleep clinic to set the pressure. Analyses were repeated, excluding those without machines, and results were essentially unchanged. The 2-week session was 2 weeks after diagnosis, rather than 2 weeks after participants obtained a CPAP machine, so data on average daily use at 2 weeks is based on fewer days and may be less reliable for those who took longer to obtain machines. Individuals who obtained machines quickly had nearly 14 days of data recording at the 2-week visit. Future studies should conrm time between diagnosis and CPAP start by contacting durable medical equipment providers and scheduling assessments for 2 weeks after machine acquisition to better assess early use rates. This is one of a few studies focusing largely on African Americans (66.7%). Previous studies suggest that interventions could help increase CPAP adherence if they were culturally congruent (Jean-Louis et al., 2008), so it is possible our feedback was not sufciently culturally congruent. Future efforts to ensure cultural congruence could tailor feedback using the cultural constructs of religiosity, collectivism, racial pride, and future and present time orientation, which are prevalent among African American women and associated with health behaviors and health-related beliefs (Kreuter et al., 2005). For example, a present rather than a future time orientation may have limited the impact of health risks presented in the feedback that are distal and thereby limited increased adherence (Steele-Moses et al., 2009). Our study population of largely low-income African American women is different from populations studied in other adherence interventions, complicating comparisons. Our sample (70% female) was comparable to the gender distribution of patients in this clinic (74% female). This is unusual given that men are more likely to develop OSA and more likely to receive treatment for OSA (Ancoli-Israel et al., 1991), and may reect the clinics high rate of Medicaid recipients, the majority of whom are women (Henry J. Kaiser Family Foundation, 2007). Our study found that a few SCT and TTM variables predicted adherence. These variables assess factors such as cognitions and behaviors and are, thus, individual-level variables. In this study, only two variables from these models predicted CPAP use: Baseline knowledge predicted therapy hours and average daily use at 2 weeks, and baseline readiness predicted total therapy hours at 3 months. The lack of relationships with other SCT and TTM variables in this study may be due to our unique sample. In this sample, perhaps inter-individual, organizational,

FEEDBACK TO IMPROVE CPAP ADHERENCE

111

or policy level factors (e.g., access to CPAP machines, lowering costs, etc.) have a greater inuence on use than individual-level factors. It is quite possible that the nancial burden of obtaining CPAP machines limited the power of other motivation and readiness factors to inuence adherence in this low-income sample. Self-efcacy has been predictive of use in several CPAP studies, as in other behavior change studies; but CPAP is more expensive than other health behaviors. Our study was more naturalistic than other studies on CPAP adherence in that participants were not provided with CPAP machines (Stepnowsky, Palau, Gifford, & Ancoli-Israel, 2007; Stepnowsky, Palau, Marler, & Gifford, 2007). The potential effect size of estimated income on machine acquisition was large in this study (d D 0:76; Cohen, 1988). The distribution of individuals who did or did not obtain machines between groups did not differ at 2 weeks, indicating that our intervention was not effective in helping individuals to overcome economic barriers. Future efforts to maximize CPAP use in low-income and African American populations should include multilevel interventions with efforts to reduce nancial barriers, improve the cultural congruence of the feedback intervention, and impact individual-level factors such as motivation and readiness. This is a preliminary study of a brief, written intervention utilizing personalized feedback that is theory driven and requires minimal provider burden. It may be a useful rst step of intervention to add to the ofce visit in which patients learn of their OSA diagnosis and receive the CPAP prescription, but should not be expected to ensure adequate adherence over time. Additional intervention is required to increase CPAP use rates above the rates we achieved with our PFR intervention, such as CPAPME or self-management (Aloia et al., 2007; Stepnowsky, Palau, Gifford, & Ancoli-Israel, 2007).

REFERENCES
Aloia, M. S., Arnedt, J. T., Riggs, R. L., Hecht, J., & Borrelli, B. (2004). Clinical management of poor adherence to CPAP: Motivational enhancement. Behavioral Sleep Medicine, 2, 205222. Aloia, M. S., Arnedt, J. T., Stepnowsky, C. J., Hecht, J., & Borrelli, B. (2005). Predicting treatment adherence in obstructive sleep apnea using principles of behavior change. Journal of Clinical Sleep Medicine, 1, 346353. Aloia, M. S., Smith, K., Arnedt, J. T., Millman, R. P., Stanchina, M., Carlisle, C., et al. (2007). Brief behavioral therapies reduce early positive airway pressure discontinuation rates in sleep apnea syndrome: Preliminary ndings. Behavioral Sleep Medicine, 5, 89104. Ancoli-Israel, S., Kripke, D. F., Klauber, M. R., Mason, W. J., Fell, R., & Kaplan, O. (1991). Sleep-disordered breathing in community-dwelling elderly. Sleep, 14, 486495. Ball, E. M., & Banks, M. B. (2001). Determinants of compliance with nasal continuous positive airway pressure treatment applied in a community setting. Sleep Medicine, 2, 195205. Bassiri, A., & Guilleminault, C. (2000). Clinical features and evaluation of obstructive sleep apneahypopnea syndrome. In M. H. Kryger, T. Roth, & W. C. Dement (Eds.), Principles and practice of sleep medicine (3rd ed.) (pp. 1043 1052). Philadelphia: W.B. Saunders. Budhiraja, R., Parthasarathy, S., Drake, C. L., Roth, T., Sharief, I., Budhiraja, P., et al. (2007). Early CPAP use identies subsequent adherence to CPAP therapy. Sleep, 30, 320324. Cartwright, R. D. (2003). Sleep apnea: A challenge for behavioral medicine. In M. L. Perlis & K. L. Lichstein (Eds.), Treating sleep disorders: Principles and practice of behavioral sleep medicine (pp. 7799). Hoboken, NJ: Wiley. Cohen, J. (1988). Statistical power and analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum Associates, Inc. Engleman, H. M., Martin, S. E., Deary, I. J., & Douglas, N. J. (1994). Effect of continuous positive airway pressure treatment on daytime function in sleep apnoea/hypopnoea syndrome. Lancet, 343, 572575.

112

ROECKLEIN ET AL.

Epstein, L. J., Kristo, D., Strollo, P. J., Friedman, N., Malhotra, A., Patil, S. P., et al. (2009). Clinical guidelines for the evaluation, management and long-term care of obstructive sleep apnea in adults. Journal of Clinical Sleep Medicine, 5, 263276. Findley, L., Unverzagt, M., Guchu, R., Fabrizio, M., Buckner, J., & Suratt, P. (1995). Vigilance and automobile accidents in patients with sleep apnea or narcolepsy. Chest, 108, 619624. Flemons, W. W., & Reimer, M. A. (1998). Development of a disease-specic health-related quality of life questionnaire for sleep apnea. American Journal of Respiratory and Critical Care Medicine, 158, 494503. The Henry J. Kaiser Family Foundation. (2007). Issue brief: An update on womens health policy. Menlo Park, CA: Author. Jean-Louis, G., von Gizycki, H., Zizi, F., Dharawat, A., Lazar, J. M., & Brown, C. D. (2008). Evaluation of sleep apnea in a sample of Black patients. Journal of Clinical Sleep Medicine, 4, 421425. Johns, M. W. (1991). A new method for measuring daytime sleepiness: The Epworth Sleepiness Scale. Sleep, 14, 540545. Kreuter, M. W., Sugg-Skinner, C., Holt, C. L., Clark, E. M., Haire-Joshu, D., Fu, Q., et al. (2005). Cultural tailoring for mammography and fruit and vegetable intake among low-income African-American women in urban public health centers. Preventive Medicine, 41, 5362. Kribbs, N. B., Pack, A. I., Kline, L. R., Smith, P. L., Schwartz, A. R., Schubert, N. M., et al. (1993). Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. American Review Respiratory Disorders, 147, 887895. Larimer, M. E., Lee, C. M., Kilmer, J. R., Fabiano, P. M., Stark, C. B., Geisner, I. M., et al. (2007). Personalized mailed feedback for college drinking prevention: A randomized clinical trial. Journal of Consulting & Clinical Psychology, 75, 285293. Mauchly, J. W. (1940). Signicance test for sphericity of a normal n-variable distribution. The Annals of Mathematical Statistics, 11, 204209. Meslier, N., Lebrun, T., Grillier-Lanoir, V., Rolland, N., Henderick, C., Sailly, J. C., et al. (1998). A French survey of 3,225 patients treated with CPAP for obstructive sleep apnoea: Benets, tolerance, compliance, and quality of life. European Respiratory Journal, 12, 185192. Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York: Guilford. Nieto, F. J., Young, T. B., Lind, B. K., Shahar, E., Samet, J. M., Redline, S., et al. (2000). Association of sleepdisordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study. Journal of the American Medical Association, 283, 18291836. Pack, A. I., Pack, A. M., Rodgman, E., Cucchiara, A., Dinges, D. F., & Schwab, C. W. (1995). Characteristics of crashes attributed to the driver having fallen asleep. Accident Analysis and Prevention, 27, 769775. Reeves-Hoche, M. K., Meck, R., & Zwillich, C. W. (1994). Nasal CPAP: An objective evaluation of patient compliance. American Journal of Respiratory and Critical Care Medicine, 149, 149154. Sigurdson, K., & Ayas, N. T. (2007). The public health and safety consequences of sleep disorders. Canadian Journal of Physiological Pharmacology, 85, 179183. Smeets, T., Kremers, S. P., de Vries, H., & Brug, J. (2007). Effects of tailored feedback on multiple health behaviors. Annals of Behavioral Medicine, 33, 117123. Steele-Moses, S. K., Russell, K. M., Kreuter, M., Monahan, P., Bourff, S., & Champion, V. L. (2009). Cultural constructs, stage of change, and adherence to mammography among low-income African American women. Journal of Health Care for the Poor and Underserved, 20, 257273. Stepnowsky, C. J., Marler, M. R., & Ancoli-Israel, S. (2002). Determinants of nasal CPAP compliance. Sleep Medicine, 3, 239247. Stepnowsky, C. J., Palau, J. J., Gifford, A. L., & Ancoli-Israel, S. (2007). A self-management approach to improving continuous positive airway pressure adherence and outcomes. Behavioral Sleep Medicine, 5, 131146. Stepnowsky, C. J., Palau, J. J., Marler, M. R., & Gifford, A. L. (2007). Pilot randomized trial of the effect of wireless telemonitoring on compliance and treatment efcacy in obstructive sleep apnea. Journal of Medical Internet Research, 9, e14. U.S. Census Bureau. (2003). American Community Survey, Data Prole, Mississippi.

Copyright of Behavioral Sleep Medicine is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.