Sociological determinants of adherence to continuous positive airway pressure in the management of sleep apnoea syndrome: protocol for a transdisciplinary, prospective observational study.

INTRODUCTION: Obstructive sleep apnoea syndrome (OSAS) is a chronic multiorgan pathology that has a negative impact on quality of life. Continuous positive airway pressure (CPAP) is the first-line treatment for OSAS. However, CPAP termination rates remain very high, and adherence to therapy is a major issue. To date, studies targeting predictive factors of CPAP adherence by OSAS patients mainly include clinical data. The social, socioeconomic, psychological, and home environment aspects have been far less studied and largely underestimated. This study aims to obtain solid quantitative results examining the relationship between the determinants of refusal, non-adherence, or termination of CPAP treatment, and in particular the pivotal role played by health literacy. METHODS AND ANALYSIS: This is a prospective, multicentre, observational study recruiting patients attending the sleep clinic of the Grenoble Alpes University Hospital, France. Consecutive adults (>18 years) recently diagnosed with OSAS and prescribed CPAP treatment with telemonitoring will be enrolled in the present study. They will benefit from home visits by a CPAP technician or nurse at CPAP initiation. Patients will then be followed up for 6 months through the telemonitoring platform of a home-care provider. The primary objective is to evaluate the impact of health literacy (health literacy, measured by the European Health Literacy Survey questionnaire (HLS-EU-16) on the refusal, non-adherence or termination of CPAP treatment in newly diagnosed OSAS patients, during the first 6 months after diagnosis. The target sample size is 250 participants. ETHICS AND DISSEMINATION: The study protocol, patient information, and the non-opposition form were approved by the French national ethics committee (CPP 2021-92, January 2022). All patients are required to have signed a written informed consent form permitting their anonymised personal and medical data to be used for clinical research purposes. We will publish the results in a peer-reviewed medical journal and on our institutional websites. TRIAL REGISTRATION NUMBER: NCT05385302.

Why People Forgo Healthcare in France: A National Survey of 164 092 Individuals to Inform Healthcare Policy-Makers.

BACKGROUND: Even in countries having nearly universal healthcare provision some individuals forgo or postpone healthcare to which they are entitled. Socioeconomic and geographic inequalities can make access to healthcare difficult for some people, such that they fail to seek it, particularly if they deem the type of care as non-essential. The need to pay at the point of care, the complexity and cost of top-up health insurance, and delays or only partial reimbursement can discourage take-up of care. This can affect the general health of the population. METHODS: To estimate the rate of forgoing healthcare in the general French population, between 2015 and 2018 we conducted a nationwide cross-sectional survey of individuals visiting French primary healthcare insurance agencies (Caisse Primaire d'Assurance Maladie, CPAM). We asked whether the person had foregone or postponed healthcare in the last 12 months, if so the types of healthcare forgone or put-off, and reasons. Individuals were stratified by the type of complementary (top-up) health insurance they had. RESULTS: Out of 164 092 individuals who responded, 158 032 were included in the analysis. Respondents had either private complementary (top-up) insurance (60%), top-up insurance subsidized by the state (29%), or no top-up health insurance (11%). Forgoers (n=40 115; 25.4%) most often lived alone (with or without children), were unemployed, and/ or female. Dental care (54%) and consultations with ophthalmologists, gynaecologists and dermatologists (41%) were most commonly forgone. The reasons were: inability to advance payment and/or to pay the uninsured part (69%), time constraints and difficulty in obtaining appointments (26%). CONCLUSION: We present a snapshot of forgoing healthcare in a developed country, highlighting the need for continuing review by policy-makers of payment regimens, insurance cover, availability and accessibility. While initiatives have already emerged from the results, further reforms are needed to address the problem of people forgoing preventative or perceived non-urgent healthcare, particularly for disadvantaged subgroups.

Impact of Healthcare Non-Take-Up on Adherence to Long-Term Positive Airway Pressure Therapy.

Background: The effectiveness of positive airway pressure therapies (PAP) is contingent on treatment adherence. We hypothesized that forgoing healthcare may be a determinant of adherence to PAP therapy. Research Question: The objectives were: (i) to assess the impact of forgoing healthcare on adherence to PAP in patients with Chronic Respiratory Failure (CRF) and patients with Obstructive Sleep Apnea Syndrome (OSAS); (ii) to compare forgoing healthcare patterns in these two chronic conditions. Study design and methods: Prospective cohort of patients with OSAS or CRF, treated with PAP therapies at home for at least 12 months. At inclusion, patients were asked to fill-in questionnaires investigating (i) healthcare forgone, (ii) deprivation (EPICES score), (iii) socio-professional and familial status. Characteristics at inclusion were extracted from medical records. PAP adherence was collected from the device's built-in time counters. Multivariable logistic regression models were used to assess the associations between healthcare forgone and the risk of being non-adherent to CPAP treatment. Results: Among 298 patients included (294 analyzed); 33.7% reported forgoing healthcare. Deprivation (EPICES score > 30) was independently associated with the risk of non-adherence (OR = 3.57, 95%CI [1.12; 11.37]). Forgoing healthcare had an additional effect on the risk of non-adherence among deprived patients (OR = 7.74, 95%CI [2.59; 23.12]). OSAS patients mainly forwent healthcare for financial reasons (49% vs. 12.5% in CRF group), whereas CRF patients forwent healthcare due to lack of mobility (25%, vs. 5.9 % in OSAS group). Interpretation: Forgoing healthcare contributes to the risk of PAP non-adherence particularly among deprived patients. Measures tailored to tackle forgoing healthcare may improve the overall quality of care in PAP therapies. Clinical Trial Registration: The study protocol was registered in ClinicalTrials.gov, identifier: NCT03591250.

[Refusing care: a gender thing?] / Le renoncement aux soins, une affaire de genre ?

Quantitative surveys reveal that a greater number of women than men report that they refuse care. This article presents three complementary approaches to gender which examine this disparity and allow us to think about the differences between men and women when it comes to health in a more complex way. These approaches are also useful for considering the conditions for equal access to healthcare for everyone.