Exploring Implementation of an Obstructive Sleep Apnea Screening Program for Community-Residing Older Adults: A Mixed Method Study

Abstract

Introduction: Obstructive Sleep Apnea (OSA) is a prevalent yet underdiagnosed condition worldwide, with significant health and economic burden. Older adults are particularly at risk but remain underrepresented in OSA research. Previous studies show that a substantial proportion of high-risk older adults did not proceed to further care after screened positive. However, little is known about the factors influencing their care-seeking behaviors and the effectiveness of education interventions in improving care-seeking.Aim: This mixed-method study aimed to examine the effectiveness of integrating health education into an OSA screening program and to identify the facilitators and barriers to OSA-related care seeking in older adults. Method: A quasi-experimental was designed comparing the proportion of individuals seek further OSA diagnostic tests in a control group (n=120) who received standard screening using the STOP-BANG questionnaire and the existing referral system with an intervention group (n=93) who additionally received verbal education and an informational pamphlet in a community health center in eastern China. Two-sample t-tests, chi-square tests, and Fisher’s exact tests were used to compare the baseline characteristics of participants in two groups. Non-adjusted, minimally adjusted, and fully adjusted logistic regressions were conducted to examine the effects of the intervention. In-depth interviews were conducted with four respirologists, three primary care workers, and three survey collectors for thematic analysis. Results: The intervention group had a lower proportion of participants with an annual income below 10,000 Chinese Yuan (1.1% vs 7.7%) and a higher proportion with incomes between 30,000 and 80,000 Chinese Yuan (53.85% vs 47.57%). No significant differences were observed in the other baseline characteristics between the intervention and the control group, including age (70.83 [Standard Deviation: 8.01] vs 69.66 [7.53] years, p=0.276), distance to clinic (1.83 [1.95] vs 2.44 [5.88] km, p=0.363), and STOP-BANG scores (4.39 [0.93] vs 4.36 [1.01], p=0.830).. The intervention led to a significant increase in care-seeking intentions and actual clinic visits. For care-seeking intention, 24.18% of participants in the intervention group expressed willingness to seek care, compared to 5.22% in the control group (Odds Ratio [OR]: 2.77, 95% CI: [1.52, 5.09]). Regarding actual clinic visits, 23.66% of the intervention group attended the clinic, compared to 5.00% in the control group (OR: 4.99, 95% CI: [2.20, 14.70]). Qualitative results revealed four major themes influencing OSA-related care-seeking: (1) individual-level factors: social networks, symptom severity, prior exposure to health promotion, (2) policies: (3) financial constraints and health insurance coverage, and (4) referral processes. Social networks, particularly with cohabitants or caregivers, facilitated care-seeking by raising symptom awareness, supporting informed decision-making, and helping navigate the healthcare system. Masked symptom severity hindered care-seeking among older adults, while exposure to health promotion events increased disease awareness and encouraged care-seeking. The Pulmonary and Critical Care Medicine policy, along with the patient outreach ("531") policy, improved the availability and accessibility of OSA diagnosis and treatment, thus facilitating care-seeking. Despite partial coverage for diagnosis and treatment by public health insurance, financial constraints remained a barrier, potentially linked to limited disease awareness. Additionally, both patients’ and providers’ limited understanding of OSA and underutilized referral pathways contributed to persistent barriers in accessing care.". Discussion: Integration of verbal education and distribution education material exhibited significant effects on increasing older adults care-seeking intentions and behaviors. The ratio of actual care-seeking behaviors was lower than reported in previous literature, but this finding is deemed to more accurately reflect real-world scenarios, given the minimal incentives provided in the current study. Future studies should evaluate the cost-effectiveness and scalability of such education-integrated screening programs at various locations. Meanwhile, the qualitative findings underscore the urgent need for enhanced public health initiatives, expanded insurance coverage for OSA treatment, and continued training of primary care providers. Strategies to sensitize and educate primary care providers, increase public health insurance coverage, and simplify the referral process for older adults should also be explored. Conclusion: Integrating disease education into a community-based screening program enhances older adults’ care-seeking intention and behavior. Current policies have largely increased the availability of related diagnostic and treatment services. However, the accessibility and affordability of these services remained restricted by limited awareness and insufficient coverage. Policies should address these challenges and future research should include an evaluation of the feasibility and cost-effectiveness of large-scale implementations of such education-integrated screening programs.