Prevalence, Knowledge and Awareness of Obstructive sleep apnea among Egyptians attending outpatient clinics.

doi:10.21203/rs.3.rs-1312171/v1

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Prevalence, Knowledge and Awareness of Obstructive sleep apnea among Egyptians attending outpatient clinics.

https://doi.org/10.21203/rs.3.rs-1312171/v1

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Purpose:
Obstructive sleep apnea (OSA) is a common sleep disorder that causes upper airway collapse leading to sleep apnea or hypopnea and is associated with serious health conditions. Despite being prevalent, it is an underdiagnosed and undertreated disease. We aimed at measuring the prevalence of OSA risk and detecting the level of knowledge of OSA among Egyptians attending outpatient clinics.

Methods:
A cross sectional study conducted at two university hospitals at Cairo using a Berlin questionnaire and OSA Knowledge and Attitude Questionnaire (OSAKA) Participants were recruited from outpatient clinics of Al-Hussein University Hospital and Al-Sayed Galal University Hospital. We used a validated Arabic translated version of the Berlin Questionnaire. Three domains (10 questions) were tested: the presence and severity of snoring, frequency of daytime sleepiness, and the presence of obesity or hypertension. A translation of 5 questions from OSA Knowledge/Attitude Questionnaire (OSAKA) that are suitable for the general population were also used.

Results:
Out of 395 participants approached, 345 participants (87%) completed the questionnaire. The age ranged from 18 to 82 years old (40.9 ± 15.5 SD). About 52% of participants were females (n=179) and 48% were males (n=166). The prevalence of high risk OSA among the studied population was 17.4% (n=60). Older ages, obesity and hypertension were found to be significantly associated with OSA risk. On the level of OSA awareness, 90.1% (n=311) of participants didn’t not have previous knowledge about OSA and there was no significant association between participants’ knowledge, and risk of OSA.

Conclusion:
Obstructive sleep apnea (OSA) was associated with older ages, obesity and hypertension. The knowledge level was far from needed among the studied group. This lack of knowledge needs to be addressed to reduce the underdiagnosis and undertreatment of obstructive sleep apnea.

Obstructive sleep apnea (OSA)

Prevalence

Knowledge

Awareness

Obesity.

Obstructive sleep apnea (OSA) is the most common sleep disorder characterized by recurrent collapse of the upper airway during sleep causing apnea or hypopnea, leading to hypoxia, hypercapnia, and sleep disturbance.^1,2

Obstructive sleep apnea (OSA) is a prevalent disease. A recent study estimated that almost 1 billion adults aged 30–69 years worldwide could have obstructive sleep apnea, with prevalence exceeding 50% in some countries.³ Risk factors include obesity, male sex, older age, menopause, adenotonsillar hypertrophy, and smoking^2,4.

Presentations vary from asymptomatic to severe symptoms of snoring, headache when waking up, daytime sleepiness, impaired concentration, and daytime fatigue¹.

Studies showed an association between OSA and serious comorbidities such as hypertension, cerebrovascular stroke, insulin resistance, decreased life quality and cognitive function^5–8.

This leads to an increased medical and economic burden due to decreased work productivity and the rise of work and traffic accidents ^9,10.

Despite its high prevalence, OSA is usually overlooked by clinicians. Often due to a lack of awareness among the general population and also among physicians, an estimated 80 to 90% of people with OSA have not reached a clinical diagnosis¹¹.

Berlin questionnaire is a beneficial screening tool widely used in epidemiological studies to identify high-risk groups of OSA¹² .Polysomnography (PSG) is the gold standard for diagnosing and determining its severity using apnea-hypopnea index (AHI), which is the number of awakening events per hour sleep¹³.

We aimed to use a Berlin questionnaire added to 5 questions from OSA Knowledge and Attitude Questionnaire (OSAKA) to assess the knowledge, awareness and prevalence of OSA among Egyptians attending outpatient clinics.

Study Design:

Cross-sectional study (Survey)

Data Collection: A questionnaire consisting of two parts, the first part is obtained from the Berlin Questionnaire which consists of 10 questions in three domains related to the presence and severity of snoring, frequency of daytime sleepiness, and the presence of obesity or hypertension, aiming at classifying the risk of OSA. An Arabic translated version of the Berlin Questionnaire was used which was validated in a previous study in Egypt¹⁴. The second part is a translation of 5 questions from OSA Knowledge/Attitude Questionnaire (OSAKA) which is originally a questionnaire for medical personnel aimed at assessing their knowledge and awareness of OSA, we have chosen 5 questions (supplement 1) that can be suitable for the general population¹⁵. Participants were approached during June 2021 in outpatient clinics of Al-Hussein University Hospital and Al-Sayed Galal University Hospital in which we got our ethics approval and communicated with local authorities. These two hospitals were chosen as they are university hospitals that have high rates of people visiting these hospitals from all over the country.

The target sample size was to collect 280 questionnaire responses from participants among the population attending out-patient clinics about their knowledge and awareness of OSA. A participant was defined as a person who is 18 years old or above.

Analysis: The data were collected, tabulated, and analyzed by SPSS (Statistical Package for Social Science) computer software program version 21 and other statistical programs.

Descriptive statistics [e.g., percentage (%), mean (x) and standard deviation (SD)], Analytic statistics were used. Chi-square test (χ2) used to indicate the presence or absence of a statistically significant difference between two qualitative variables. Mann-Whitney test used to compare differences between two independent groups when the dependent variable is either ordinal or continuous, but not normally distributed. P-value of <0.05 was considered statistically significant. Calculation of the risk prevalence of OSA (high risk or low risk) was done according to the response to the Berlin questionnaire (score of the three categories).

A total number of 395 participants were approached to fill the questionnaire. Out of them, 345 participants (87%) completed the questionnaire. Age of participants ranged from 18-82, mean and standard deviation (SD) of ages are 40.9 ± 15.5. Age was found to have a significant association with OSA. Mean Body mass index (BMI) of participants was 28.7 (SD, ± 6.7) kg/m² and ranged from 15.6 to 52.4 kg/m² and had a significant association with OSA. (Table 6). Females represented 51.9% of all participants (n=179) and smokers accounted for 20.9% (n=72) of participants.

Table 1

Characteristics of study participants (N = 345).
The variable	The sample (N=345)
The variable	Frequency	%
Age: (year) 18 - 30 - 60 + Mean ± SD Range	102 188 55	29.5 54.5 16
Age: (year) 18 - 30 - 60 + Mean ± SD Range	40.9 ± 15.5 18 – 82
Sex: Male Female	166 179	48.1 51.9
Weight: (Kg) Mean ± SD Range	78.6 ± 18.9 40 – 170
Height: (Cm) Mean ± SD Range	165.8 ± 9.9 105 – 200
Body Mass Index (BMI) Mean ± SD Range	28.7 ± 6.7 15.6 - 52.4
Smoking: Yes No	72 273	20.9 79.1
Having high blood pressure Yes No Don’t know	65 248 32	18.8 71.9 9.3
SD: standard deviation, %: percentage, Kg: kilogram, Cm: centimeter

In addition, 18.8% (n=65) had a history of high blood pressure, 71.9% (n=248) did not have a history of high blood pressure and 9.3% (n=32) did not know if they had high blood pressure or not. Participants with high blood pressure were at higher risk to develop OSA (p-value<0.001).

On assessing snoring among the participants, we found that 112 out of 345 (32.5%) were snoring (p-value<0.001), 205 are not and 28 do not know. The distribution of its characters and percent distribution of snoring among the study participants are summarized in Table 2, Figure 2.

Table 2

Frequent distribution of snoring and its characters among the study participants (N = 345).
The variable	The sample (N=345)
The variable	Frequency	%
Occurrence of snoring: (N=345) Yes No Don’t know	112 205 28	32.5 59.4 8.1
Prevalence of snoring among the study participants = 32.5% (112)
Nature of snoring: (N=112) Slightly louder than breathing As loud as talking Louder than talking High loud to be heard from other room	39 35 11 27	34.8 31.3 9.8 24.1
Times of snoring: (N=112) Almost every day 3-4 times per week 1-2 times per week 1-2 times per month Rarely or never	44 18 22 23 5	39.3 16.1 19.6 20.5 4.5
Being snoring bothers people: (N=112) Yes No Don’t know	54 49 9	48.2 43.8 8.0
Observation of having sleep apnea: (N=112) Almost every day 3-4 times per week 1-2 times per week 1-2 times per month Rarely or never	0 10 7 8 87	0 8.9 6.3 7.1 77.7

On assessing outcomes associated with OSA such as behavior and sleep per day, we found that 28.1% of participants (n=97) are feeling fatigue after sleep almost every day, 52 of them had a high risk of developing OSA (p-value<0.001). In addition, 27% of participants (n=93) are feeling fatigue during waking time almost every day with significant association (p-value<0.001) for developing OSA.

On evaluating sleep during driving, we found that only 4.6% (n=16) of participants said that they fall asleep during driving. Furthermore, 12.5% (n=2) of those participants are falling asleep while driving almost every day which puts them at high risk of causing car accidents. (Table 3) (Figure 3)

Table 3

Frequent distribution of some of OSA associated outcomes (behavior and sleep) during the day.
The variable	The sample (N=345)
The variable	Frequency	%
Feeling of fatigue after sleep: Almost every day 3-4 times per week 1-2 times per week 1-2 times per month Rarely or never	97 44 63 24 117	28.1 12.8 18.3 7 33.9
Feeling of fatigue during waking time: Almost every day 3-4 times per week 1-2 times per week 1-2 times per month Rarely or never	93 47 52 20 133	27 13.6 15.1 5.8 38.6
Sleeping during driving: Yes No Have no car	16 79 250	4.6 22.9 72.5
Times of falling asleep while driving. (N=16) • Almost every day • 3-4 times per week • 1-2 times per week • 1-2 times per month • Rarely or never	2 2 7 2 3	12.5 12.5 43.8 12.5 18.8

We found that the percentage of high risk OSA was 17.4% (n=60) among all participants and this was related to their characteristics and behaviors. (Table 5) (Figure 5)

Obstructive sleep apnea: knowledge and awareness,

Responses of all participants to the knowledge assessment questionnaire regarding obstructive sleep apnea are shown in Tables 4 and Figure 4.

Table 4

Assessment of OSA-related knowledge and awareness among the study participants.
The variable	The sample (N=345)
The variable	Frequency	%
Having a previous knowledge about OSA: Yes No	34 311	9.9 90.1
OSA is associated to HTN: Yes No Don’t know	26 11 308	7.5 3.2 89.3
OSA is associated with high incidence of crashes: Yes No Don’t know	26 18 301	7.5 5.2 87.2
OSA is more common in women: Yes No Don’t know	16 22 307	4.6 6.4 89.0
Diagnosed with OSA: Yes No	7 338	2 98

We found that 90.1% (n=311) of participants did not have previous knowledge about OSA. While assessing their knowledge and awareness that OSA is associated with hypertension and with a high incidence of crashes, we found that 89.3% (n=308) and 87.2% (n=301) of participants, respectively, said that they do not know, and only 7.5% (n=26) of participants knew the association of OSA with hypertension and high incidence of crashes. In addition, only 4.6% (n=16) of the participants know that OSA is more common in females. (Table 4)

Only 2% (n=7) of the participants knew that they were diagnosed with OSA. There was no significant association between participants’ knowledge, awareness, and risk prevalence of OSA (p-value=0.634).

Table 5

The risk prevalence of OSA among the study participants.
The variable	The sample (N=345)
The variable	Frequency	%
Risk prevalence of OSA: High risk Low risk	60 285	17.4 82.6

Table 6

The risk prevalence of OSA in relation to the different characteristics of the study participants.
P .value	Test	Risk prevalence of OSA
		High (60)			Low (285)
		%		No.	%	No.
.000*	χ²= 23.21	8.3 75 16.7		5 45 10	34 50.2 15.8	97 143 45	Age § 18 - § 30 - § 60 +
.778	χ²=.103	50 50		30 30	52.3 47.7	136 149	Sex § Male § Female
.000*	Mw=4822.5	90.1 ± 19.1 235.1			76.2 ± 18.1 159.92		Weight: (Kg) Mean ± SD Mean Rank
.583	Mw= 8166	166.95 ± 10.1 179.39			165.65 ± 9.9 171.65		Height: (Cm) Mean ± SD Mean Rank
.000*	Mw= 5091.5	32.5 ± 6.7 230.64			27.8 ± 6.5 160.86		BMI Mean ± SD Mean Rank
.119	χ²= 2.450	28.3 71.7	17 43		19.3 80.7	55 230	Smoking: § Yes § No
.000*	χ²= 68.918	56.7 41.7 1.7	34 25 1		10.9 78.2 10.9	31 223 31	Having HTN § Yes § No § Don’t know

Although OSA is a common disease that could impact general health, no previous screening was conducted to assess the prevalence of its risk among Egyptians. This study aimed to provide some data about OSA and to compare the knowledge and attitude between the high and low risk groups.

Our study results revealed that 17.4% of the participants were classified in the high-risk category for OSA. The risk was more among older population, obese and hypertensive participants. The vast majority of those at high risk showed no previous knowledge about the disease. Numerous studies were conducted to measure the prevalence in different countries using BQ and came with comparable results. In South Korea, nationwide screening showed a prevalence of 15.8%¹⁶, while a sample of the working population in Kuwait had 20% prevalence¹⁷. Another study compared between the US and European countries and found the risk prevalence to be 35.8% and 26.3% respectively¹⁸. Those differences could be traced back to demographic differences between study participants.

The association between older age and OSA risk was observed in our study. Accumulating evidence supported the association between age and OSA^19,20. Duran et al.²¹ applied multiple logistic regression on a study sample aged 30 to 70 years old and detected an increasing OSA percentage with increasing age that ranged from 35% in (30 – 39 years) male age group to 49% in (60-70 years) age group.

Obesity (defined as BMI ≥ 30) was positively associated with OSA and considered as a risk factor ^16–18. A rise by 10% in body weight could result in a six-fold increase in the OSA risk²². In addition to the OSA risk, excess BMI could exacerbate the desaturation of oxygen amidst the apnea and hypopnea events²³. Conversely, OSA could predispose weight gain due to metabolic disturbances and daytime sleepiness²⁴.

Of our study sample, 56.7% of the high-risk group were already diagnosed with hypertension compared to 10.9% in the low-risk group, and a statistical significance was found (p-value<0.001). OSA is seen as a risk factor of hypertension²⁵ independent from other confounding comorbidities that could be found in OSA patients²⁶. In addition, OSA has a well-established relation as a risk factor for other cardiovascular diseases e.g. heart failure, coronary heart diseases, and even atrial fibrillation ^27,28, therefore, OSA patients have a higher rate of cardiovascular morbidity and mortality²⁹. Interestingly, treating patients with continuous positive airway pressure (CPAP) resulted in lowering systolic blood pressure³⁰, an effect that could be associated with reduction of major complications such as heart failure and stroke³¹.

Many studies considered male gender to be a risk factor for OSA with a male to female ratio of 2-3: 1 ³². In our study, men showed slightly higher risk (18%) than women (16.75%) but with no statistical significance, in accordance with other population-based studies ^16,17. In fact, the gender disparity, demonstrated by some studies, tends to decline in older ages more than 60 years³³ or 50 years ¹⁶. This could be explained on the basis of the severity of OSA that increases in women after menopause, consequently, there was no significant difference in apnea-hypopnea index (AHI) between postmenopausal women and men of the same age³³. The gender factor could also differ from society to another, a study on 2946 Saudi participants aged more than 60 years old showed risk prevalence in women more than men (60.8% vs. 44.2%, respectively)³⁴. Some researchers suggest that women could have different symptom profile that leave them underrecognized by the current diagnostic tools.³⁵ More research has to be done to investigate the relation between gender and OSA.

On the level of knowledge and attitude testing, the high-risk group showed no significant awareness about the disease with only 11.7% in contrast to 9.5% in the low-risk group. The absent awareness can be mainly attributed mainly to suboptimal OSA knowledge of physicians. An Egyptian study conducted for knowledge assessment using OSAKA questionnaire, in response to 18 questions, critical care physicians had a lower mean score for knowledge (10.05 ± 2.3) about OSA ³⁶. This low level is concordant with studies conducted in different countries; on a regional level, primary care doctors from the Middle East and North Africa (MENA) region had a low mean score for knowledge (12.6 ± 2.5) about OSA³⁷, while primary care doctors in Latin America hadn’t shown much difference where the mean score was 60% (equal to 10.8)³⁸. In Italy, anesthetists had a mean knowledge score of 12 ³⁹.

To our knowledge, our study is the first to provide such epidemiological information on OSA risk in patients attending out-patient clinics in Egypt and to measure the knowledge level in the high and low risk groups. The questionnaire was chosen because it is inexpensive and standardized with easy analysis and fast results. The study sample is strengthened by achieving gender balance and including variant age groups, enabling us to observe the differences among them. On the other hand, convenience sampling could be a limitation that affects the generalizability of the results. Another limitation was using a self-report questionnaire considering the possible recall bias of participants. Additionally, Berlin questionnaire is shown to be less accurate in comparison with other diagnostic tools such as polysomnography (gold diagnostic tool) with a sensitivity and specificity that could reach 58.8% and 77.76% and a high negative predictive value 82.9% when AHI cutoff is <15 ⁴⁰ .Using a questionnaire also has disadvantages of misunderstanding and skipped questions which we overcame using Arabic-translated questionnaires and not including responses who had incomplete answers¹⁴.

Many conclusions could be deduced from our study. Firstly, lifestyle changes and control of the reversible risk factors such as obesity can be a mainline in the management of OSA. Different studies highlighted the effect of weight reduction on OSA; 10% reduction in body weight can decrease AHI by 26% ²². Other studies estimated a reduction in AHI by 47% and 61% could be achieved by 9% and 17% body weight reduction ^41,42

Secondly, OSA is prevalent among drivers and pilots and its effects may extend beyond medical comorbidities to increase the risk of car traffic accidents ^43,44. Hence, we recommend OSA screening for vital and related jobs such as drivers and pilots

Furthermore, this study underlines the need for raising awareness of OSA among the public and, in advance, the medical personnel. Using the different educational tools to teach medical students could elevate the level of knowledge⁴⁵. Information about OSA should be disseminated to the public to alter the perception of snoring from being a social problem to being a possible symptom of OSA. Recognizing the risk factors as well as complications of OSA is essential to overcome the underdiagnosis and undertreatment of OSA. Recently, OSA has been identified as a risk factor for severe outcomes in COVID-19 patients and is associated with higher mortality rates⁴⁶.

Obstructive sleep apnea (OSA) was associated with older ages, obesity and hypertension. The knowledge level was far from needed among the studied high and low risk groups. This study highlights the urge to control the risk factors associated with OSA as an essential line of management. Noteworthy, there is a conspicuous need to increase awareness of OSA among the medical community and the public in our way to alleviate and better the underdiagnosis and undertreatment of OSA.

Acknowledgement:

We would like to offer special regards to Prof. Dr. Hosni Khairy for supervising the early stages of the study. Although he tragically lost his life, he continues to inspire us by his example and dedication to the students he served over the course of his career. We do also acknowledge the role of Dr. Abdallah Al-balsha for his participation in developing the research idea.

Funding:

No funding was received for this research.

Conflict of Interest:

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers' bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Ethical approval:

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee of Al-Azhar Faculty of Medicine and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent:

Informed consent was obtained from all individual participants included in the study.

Data Availability Statement:

All data generated or analyzed during this study are included in this published article (and its supplementary information files).

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Prevalence, Knowledge and Awareness of Obstructive sleep apnea among Egyptians attending outpatient clinics.

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