Concerns Regarding Data Modelling and Interpretation in Ruuska et al.

Obstructive sleep apnea (OSA) is a prevalent, under-diagnosed, and under-treated sleep disorder among Hispanics []. OSA causes daytime sleepiness, decreased quality of life, increases risk for cardiometabolic disease and dementias [–]. The first-line treatment for OSA, positive airway pressure (PAP), is highly effective at treating OSA symptoms in the patient and improving sleep in both the patient and bedpartner, however approximately half of patients are non-adherent [–]. Despite higher rates of OSA risk factors among Latinos (e.g., obesity), they remain under-represented in OSA research []. There are significant racial and socioeconomic disparities in PAP adherence [–], though most of this work has focused on racial (i.e., Black versus White) differences. The limited available evidence about PAP adherence among Latino adults is mixed [–], suggesting considerable heterogeneity in PAP adherence based on national origin or sociocultural background, acculturation, and individual and neighborhood-level socioeconomic characteristics. For example, one study focused on Latino patients with OSA found that the patienťs perceived benefit with PAP therapy was associated with greater PAP adherence, whereas primary language was not associated with PAP adherence []. Another study found lower continuous positive airway pressure (CPAP) adherence in neighborhoods with greater proportions of Black or Latino residents []. There is a strong rationale for addressing PAP adherence using culturally adapted interventions, particularly within the context of the couple and family []. The consequences of OSA extend beyond the individual with OSA, also affecting the romantic partner or spouse []. For example, bedpartners of individuals with OSA are often “casualties” of untreated or poorly treated OSA [], [,], as the nocturnal symptoms of OSA, including snoring, gasping for air, or choking are highly disruptive to the bedpartner's sleep and can contribute to hyper-vigilance, which is a risk factor for insomnia []. Indeed, partners of snorers are at 3 times greater risk of insomnia [] and are also at elevated risk of depression and reduced quality of life (QOL) [,,]. Family relationships are likely to be even more important among Hispanic patients. As represented by the core cultural value of , interdependence among family members and the active maintenance of harmonious pro-social family relationships configures everyday social practices and decision making, such as with whom and where an individual lives and the role of family in important life decisions [,]. For example, Latino people are more likely to rely on family members to provide support and care, rather than non-familial supportive services [] a key hypothesized protective factor for health among Latinos []. Existing PAP adherence interventions have been targeted exclusively towards the OSA patient, neglecting to consider the immediate interpersonal and broader sociocultural context [], which is particularly important for racial and ethnic minority patients affected by health disparities. Given that reimbursement of PAP often depends on 90-day usage, such findings highlight the importance of considering broader sociocultural determinants of adherence and providing targeted and culturally adapted interventions to promote PAP adherence among minoritized populations in order to promote health equity. Study team members Baron and Troxel developed and tested WePAP [], a couples-based intervention for PAP adherence. WePAP was acceptable, feasible and showed promising effects on patient adherence, and both partners’ sleep quality as well as relationship quality. A limitation of our pilot was that our sample was primarily comprised of non-Hispanic White, highly educated patients (84% white, 43% held graduate degrees), and there was limited variability across conditions, as patients in both the intervention and information-control group had very high PAP adherence (>80% using PAP for more than 4 h per night at 3-month follow-up), though those in the WePAP group had higher non-statistically significant higher adherence than those in the information control group. As a next step, our team developed Nuestro Sueño, by adapting WePAP for Latino couples, utilizing the cultural adaptation framework by Barrera et al. [] A cultural adaptation involves the systematic Utilizing both “top down” and “bottom up” approaches, our team utilized discussions with a community advisory board (CAB), focus groups and dyadic interviews to adapt language, content, visual images to create the 3 session Nuestro Sueño intervention.