| dc.description.abstract | Aims: To systematically review the factors influencing adherence to mandibular advancement appliances (MAA) in adults with obstructive sleep apnoea (OSA) and the potential effectiveness of interventions to promote improved adherence. To assess the effectiveness of a stage-matched intervention on adherence to MAA in participants with OSA. To qualitatively explore and understand adherent and non-adherent patients’ experiences. Methods: A systematic review and meta-analysis were performed. A randomised parallel-arm, Hospital-based, clinical trial was undertaken at the Royal London Dental Hospital, UK. Fifty-six participants (Adults 18 years or over) with newly diagnosed OSA were enrolled in the study and randomised to intervention care (IC) and standardized care (SC) groups. Participants in the SC group received routine care whilst participants in the IC group received the stage-matched intervention, developed using the behaviour change model, the Health action process approach (HAPA). Data indicating MAA adherence was collected both objectively and subjectively, from micro-sensors embedded in the MAA design and sleep diaries, respectively at 3- and 6-months. In addition, a range of questionnaires designed to assess risk perception, outcome expectancy, and self-efficacy (SEMSA) and quality of sleep and life, socio-economic and social support scales were used. One-to-one interviews were conducted to identify patients’ perceptions concerning adherence and non-adherence. The Behaviour change taxonomy by Crane et al. was applied as a coding framework to identify behaviour change techniques influencing adherence. Results: The review observed a weak relationship between objective adherence and patient and disease characteristics such as age, sex, obesity, AHI, and daytime sleepiness. Non-adherent patients reported more side effects than users and tended to discontinue treatment within the first 3 months. Increased patient adherence was identified with custom-made MAA in comparison to ready-made MAA. The review identified limited evidence concerning the influence of psychological and social factors on MAA adherence. Given that majority of the studies relied upon patient-reported adherence, the review observed a considerable lack of objective adherence monitoring. The mean objective adherence for 30 participants at 3-month (IC = 15, SC = 15) was 2.02 (SD = 2.68) vs 2.63 (SD = 2.57) hours/night in the IC and SC group respectively. Whilst the mean objective adherence for 25 participants at 6-month (IC = 10, SC = 15) was 2.42 (SD = 2.59) vs 3.21 (SD = 3.37) hours/night for IC and SC groups respectively. No correlation was seen between ESS (p = 0.24), PSQI (p = 0.96), social support (p = 0.52), socio-economic position (p = 0.96) and mean adherence. However, linear regression for adherence presented a positive coefficient for risk perception (p = 0.035) (r2 = 0.16) and outcome expectancy (p = 0.003) (r2 = 0.28). The behaviour change techniques that were observed to have a positive influence on adherence were reward and threat, repetition and substitution, antecedents, associations, natural consequences, feedback and monitoring, social support and comparison of outcomes. Whilst a negative influence on adherence was observed with antecedents. Conclusion: Further research would be beneficial to describe the determinants of adherence, such as risk perception, self-efficacy, and outcome expectancy and to facilitate patient education and development of tailor-made interventions to enhance adherence to MAA. Similarly, the lack of objective adherence monitoring necessitates the need for future studies that assess adherence objectively. The analysis to-date demonstrates the stage-matched intervention does not enhance adherence to MAA. Notwithstanding this, adherence might be dependent on predictors such as risk perception and outcome expectancy. A varied range of behaviour change techniques was observed in the current study that aided participants in the initiation, enactment and maintenance of the behaviour. Further research is needed to better understand the application of these techniques in a clinical setting to enhance MAA adherence. Limitation: The clinical trial was severely impacted due to the COVID-19 Pandemic as eight months of recruitment and data collection time was lost. Hence, a limited data quantity of data was available for analysis. | en_US |
