HLTH 6038 Week 11 Applied Theory Paper Example

The Integrated Behavioral Model Fitted to CPAP Use in the First 90 Days After a Sleep Apnea Diagnosis: Why Its Environmental Constraint, Skill and Habit Elements Make It the Right Model, Defended Against the Objection That the Problem Is the Mask

Student Name

Walden University

HLTH 6038: Health Behavior Theory

Instructor Name

Month Day, Year

The Integrated Behavioral Model Fitted to CPAP Use in the First 90 Days After a Sleep Apnea Diagnosis: Why Its Environmental Constraint, Skill and Habit Elements Make It the Right Model, Defended Against the Objection That the Problem Is the Mask

Thesis

The Integrated Behavioral Model is the best available theory for explaining whether adults newly diagnosed with obstructive sleep apnea use continuous positive airway pressure (CPAP) at the level their coverage requires in the first 90 days of therapy. It fits because it joins the reasoned action determinants of intention to three elements that earlier models left out, knowledge and skill, environmental constraints and habit, and those three explain the patterns of early CPAP use that intention alone cannot.

The Behavior, Defined Narrowly

The behavior is CPAP adherence measured as device use for at least four hours on at least 70% of the nights in any run of 30 straight days within the first three months of therapy. This is the definition Medicare uses to decide whether to continue covering the device (Centers for Medicare & Medicaid Services [CMS], 2008), and it is recorded objectively by the machine. The definition is defended here because measurement conventions differ across the literature: Weaver and Grunstein (2008) note that when the threshold for adherence is set above four hours a night, between 46% and 83% of patients have been reported as nonadherent, and other studies use different thresholds. A narrow, objective definition tied to a real consequence, losing coverage, keeps the paper's claims checkable.

The Model

The Integrated Behavioral Model extends the reasoned action tradition, including the planned behavior version (Ajzen, 1991). Intention to perform a behavior is shaped by attitude, perceived norm and personal agency. Attitude has an experiential side, how the person feels about the behavior, and an instrumental side, what outcomes they expect. Perceived norm includes injunctive norms, what others think one should do, and descriptive norms, what others actually do. Personal agency combines perceived control and self-efficacy. The model then adds that intention leads to behavior only when the person has the knowledge and skill to carry it out, when environmental constraints do not prevent it, when the behavior is salient and, for repeated behaviors, when habit supports it (Montaño & Kasprzyk, 2015).

The Evidence on Early CPAP Use

Three features of CPAP use stand out in the literature. First, adherence is poor and has not improved much. A review of 82 studies over 20 years found an overall nonadherence rate of 34.1% with no significant improvement over the period, and behavioral interventions improved use by about an hour a night on average (Rotenberg et al., 2016). Second, the pattern is set early. Weaver and Grunstein (2008) report that the decision to embrace CPAP occurs during the first few days of treatment. Third, no single factor predicts adherence consistently, and patients' perceptions of symptoms and improvement may matter more than physiological severity (Weaver & Grunstein, 2008).

Applying the Model

Intention and Its Determinants

At diagnosis, most patients intend to use the device; they have been told it will help, and they want to sleep better. The experiential attitude is the weak point: the first nights with a mask often feel worse than nights without it. The instrumental attitude may be positive, but the experiential one turns negative quickly. Perceived norm comes mainly from a bed partner, whose complaints about snoring create a strong injunctive norm in favor of use and whose complaints about machine noise may create one against it. Personal agency depends on whether the patient believes they can sleep with the mask on, which is the self-efficacy question.

Knowledge and Skill

CPAP requires skills that intention cannot supply: fitting the mask, adjusting straps, using the humidifier, reattaching the mask after waking in the night. A patient who intends to use the device but cannot stop air leaking at the mask's edge will remove it. The model's skill element explains why adherence fails in patients with strong intentions.

Environmental Constraints

The environment includes the bedroom, the bed partner, the power supply and, importantly, the supply chain. A cracked cushion that cannot be replaced for two weeks, a machine that is too loud for a shared room or a trip without a travel kit are constraints that stop use regardless of intention. The model treats these as direct barriers between intention and behavior.

Habit

The adherence definition rewards nightly use. The model's habit element predicts that patients who use the device every night from the start build an automatic routine, while those who use it intermittently do not. This fits the evidence that the first days set the pattern (Weaver & Grunstein, 2008): a habit forms or fails to form early.

The Objection

The strongest objection is that CPAP adherence is not a behavioral problem at all but a device problem. If the mask fits and the pressure is comfortable, patients use it; if not, they do not. On this view, the right response is engineering, not theory, and a cognitive model adds nothing.

The objection has force. Mask fit and comfort matter, and the modest gains from behavioral interventions (Rotenberg et al., 2016) suggest that cognition alone will not solve the problem.

But the objection assumes that the model is purely cognitive. The Integrated Behavioral Model is not. Its skill element covers mask fitting, its environmental constraint element covers equipment failures and supply delays and its experiential attitude element covers how the device feels. The device problem the objection describes sits inside the model rather than outside it. What the model adds is the recognition that device fixes work through the patient's experience, skills and routine: a better mask improves the experiential attitude, a fitting lesson builds skill and a quick cushion replacement removes a constraint. Engineering and behavior are not rivals here; the model explains how one shapes the other.

What the Fit Implies

If the model fits, the first two weeks should concentrate on skill, constraint removal and habit: a mask fitting visit on day 2, a supplier who replaces parts within 48 hours and a nightly use target from the first night, with data from the machine reviewed at one week. Each step targets a named element of the model.

Conclusion

The Integrated Behavioral Model explains early CPAP adherence better than models built on intention alone, because the reasons patients stop, discomfort, poor fit, equipment problems and an unformed routine, map onto its experiential attitude, skill, environmental constraint and habit elements. The device objection is real, but the model absorbs it rather than being refuted by it.

References

Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50(2), 179-211. https://doi.org/10.1016/0749-5978(91)90020-T

Centers for Medicare & Medicaid Services. (2008). National coverage determination: Continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA) (240.4). https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=226

Montaño, D. E., & Kasprzyk, D. (2015). Theory of reasoned action, theory of planned behavior, and the integrated behavioral model. In K. Glanz, B. K. Rimer, & K. Viswanath (Eds.), Health behavior: Theory, research, and practice (5th ed., pp. 95-124). Jossey-Bass.

Rotenberg, B. W., Murariu, D., & Pang, K. P. (2016). Trends in CPAP adherence over twenty years of data collection: A flattened curve. Journal of Otolaryngology: Head & Neck Surgery, 45, Article 43. https://doi.org/10.1186/s40463-016-0156-0

Weaver, T. E., & Grunstein, R. R. (2008). Adherence to continuous positive airway pressure therapy: The challenge to effective treatment. Proceedings of the American Thoracic Society, 5(2), 173-178. https://doi.org/10.1513/pats.200708-119MG