Sleep Medicine 14 (2013) 973–977

Contents lists available at ScienceDirect

Sleep Medicine
journal homepage: www.elsevier.com/locate/sleep

Original Article

Attitudes and knowledge about obstructive sleep apnea among Latin

American primary care physicians
Ivan Cherrez Ojeda a,⇑, Donna B. Jeffe b, Thomas Guerrero c, Ronnie Mantilla d, Ilka Santoro e,
Gustavo Gabino f, Juan C. Calderon a, Fernan Caballero g, Jose Mori h, Annia Cherrez i
a
Respiralab Research Center Kennedy Hospital, Guayaquil, Ecuador
b
Division of Health Behavior Research, Department of Medicine, Washington University School of Medicine, Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington
University School of Medicine, St. Louis, MO, USA
c
Mental Health Research Institute /Brown University, Providence, RI, USA
d
Capital Health Regional Medical Center, Trenton, NJ, USA
e
Respiratory Division, Federal University of Sao Paulo, Brazil
f
Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
g
Medical Center La Trinidad, Caracas, Venezuela
h
Department of Allergy and Immunology, Clínica San Borja, Lima, Peru
i
University of Heidelberg, School of Medicine, Heidelberg, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: We aimed to evaluate Latin American primary care physicians’ knowledge and attitudes
Received 31 December 2012 about obstructive sleep apnea (OSA) using a Spanish-language version of the OSA Knowledge and Atti-
Received in revised form 1 June 2013 tudes (OSAKA) questionnaire and to evaluate its psychometric properties.
Accepted 12 June 2013
Methods: We used a cross-sectional survey of general practice physicians in Ecuador, Peru, and Venezuela
Available online 22 August 2013
who completed the Spanish-language version OSAKA questionnaire.
Results: Of 684 primary care physicians surveyed, 367 (65%) responded (mean age, 45 years; range, 21–
Keywords:
75 years). Mean total knowledge (proportion of 18 items correctly answered) was 60% (range, 0–100%).
Obstructive sleep apnea
Attitudes
Less than half of physicians correctly answered the questions about the association between OSA and
Knowledge hypertension. We found no significant differences in overall knowledge in gender or time since gradua-
Primary care tion (65 years vs >5 years). Although 73.5% of the physicians felt confident in identifying patients at risk
OSAKA questionnaire for OSA, only 35.4% felt confident in managing those patients and 22.1% felt confident in managing
Validation patients with continuous positive airway pressure (CPAP) therapy. The Spanish-language version of the
OSAKA questionnaire had comparable psychometric properties to the English-language version.
Conclusions: This Spanish-language version of the OSAKA yielded considerable variance in Spanish-
speaking physicians’ knowledge about OSA and confidence in identifying and managing patients with
OSA. Focused OSA education for Latin American general physicians is needed.
Ó 2013 Elsevier B.V. All rights reserved.

1. Introduction OSA is an independent risk factor for cardiovascular diseases,

Recognition of obstructive sleep apnea (OSA) as an important
health risk factor has grown over the last 20 years [1]. It is esti-
mated that 2–5% of the adult population is at risk for OSA, defined
as an apnea-hypopnea index (AHI) >5 events per hour [2–4]. The
prevalence of OSA might increase in parallel with the rise in obes-
ity and in a generally longer lifespan [5–7]. A high frequency of
sleep-related symptoms has been reported in the general Hispanic
population [8].
⇑ Corresponding author. Address: Respiralab Research Center, Kennedy Hospital
Delta Seccion, Guayaquil, Ecuador. Tel.: +593 42288450; fax: +593 42288457.
E-mail address: icherrez@yahoo.com (I. Cherrez Ojeda).
depression, and diabetes mellitus [9,10], with a substantial societal
economic burden [11]. Following treatment for OSA, healthcare
expenditures were found to significantly decrease among patients
who were adherent to treatment [12]. Therefore, OSA can lead to a
multitude of consequences when left undiagnosed or untreated.
Unfortunately, an estimated 82% of men and 93% of women with
moderate or severe OSA have remained undiagnosed [13,14],
which may be attributed to a lack of sleep health knowledge
among patients and also among physicians [15].
Despite the high prevalence and clinical significance of OSA, lit-
tle is known about primary care Latin American physicians’ ability
to identify and manage patients with OSA [16]. The aim of our
study was to evaluate the knowledge and attitudes of OSA among
Latin American primary care physicians using a Spanish-language

1389-9457/$ - see front matter Ó 2013 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.sleep.2013.06.005
974 I. Cherrez Ojeda et al. / Sleep Medicine 14 (2013) 973–977
version of the OSA Knowledge and Attitudes (OSAKA) question-
naire, which was originally developed in the United States
[17,18]. We also evaluated the psychometric properties of this
Spanish-language version of the OSAKA questionnaire.
2. Methods
2.1. Study design
We conducted an anonymous cross-sectional survey of primary
care physicians (family practitioners and residents training in this
discipline) who were attending scientific medical conferences in
six cities, including Quito and Guayaquil, Ecuador (July 2010 to
September 2010); Lima, Peru (June 2011); and Caracas, Valencia,
and Maracaibo, Venezuela (May 2010 to September 2010). The sur-
veys were administered during international meetings of allergy,
asthma, and respiratory medicine in Guayaquil, Lima, and Caracas.
In Valencia and Maracaibo, the study was conducted during local
conferences about allergy and respiratory medicine. We consulted
with our institutional committee who approved the study. After re-
ceipt of participants’ verbal consent, the survey was voluntarily
completed; no financial incentive was offered.
2.2. Study survey
We used the OSAKA questionnaire to measure physician’s
knowledge and attitudes about OSA [17,18]. The OSAKA question-
naire was developed and validated in the United States to assess
physicians’ knowledge and attitudes concerning the identification
and management of patients with OSA [17,18]. We used a rigorous
method of validation of the translated version of the OSAKA [19],
which we briefly described. Two of the investigators translated
the OSAKA to Spanish. Next the Spanish-language version was
translated to English by a third investigator who did not know
the original version of OSAKA. Then the back-translated English-
language version of the new Spanish-language questionnaire was
compared with the original English-language version; each item
on the back-translated English-language version was ranked by
30 individuals who were bilingual and independent of the study
team for comparability and similarity of interpretability with the
same item on the original English-language version. Any translated
item with a mean score >3 (seven was the worst agreement and
one was the best agreement) was formally reviewed and corrected.
The revised item was then translated back to English and com-
pared again with the original English-language version of that
item. This process continued until the mean scores for each item
indicated a valid version (63 on each of the comparability and
interpretability rankings, and preferably <2.5 on the interpretabil-
ity rankings) [19].
The OSAKA questionnaire consisted of 18 knowledge items and
5 questions related to attitudes about OSA. The knowledge items
covered OSA domains, including epidemiology, pathophysiology,
symptoms, diagnosis, and treatment. Options for response to the
OSAKA knowledge questions were true or false with a third option
of do not know, which was scored as an incorrect response. The to-
tal knowledge score was computed as the percentage of correct an-
swers to the 18 knowledge questions and ranged from zero to
100%. The first two attitude questions asked about the importance
of OSA, and responses were scored on a five-point Likert scale,
ranging from one (not important) to five (extremely important).
The remaining three attitude questions dealt with one’s confidence
in diagnosing and treating patients with OSA, and responses were
scored from one (strongly disagree) to five (strongly agree). Mean
scores were computed for each of the two attitude scales.
In addition to the OSAKA questionnaire, the survey included
questions related to age, gender, year of medical school graduation,
and years in medical practice.
2.3. Data analysis
We used descriptive statistics to summarize responses to the
individual questions on the OSAKA questionnaire. We used v2 tests
to compare proportions across countries, gender, and years in prac-
tice after medical graduation (stratified by 65 years after gradua-
tion or >5 years). Spearman rank correlation coefficients were
used to assess the relationships between the OSAKA knowledge to-
tal score and attitudes about sleep apnea. Statistical tests were per-
formed using SPSS version 13 (SPSS, Inc, Chicago, IL, 2000). A P
value of less than .05 was considered significant for all tests.
3. Results
Of the 684 primary care physicians who received a survey, 367
(65%) returned a completed questionnaire. The mean (standard
deviation [SD]) age of respondents was 45 years (SD, 11 years;
range, 21–75 years), with 53% being women. The mean (SD) number
of years in practice was 18 years (SD, 11 years; range, 0–47 years),
with 81% who reported having graduated more than 5 years ago.
3.1. Knowledge
The mean total knowledge score (proportion of 18 items cor-
rectly answered) was 60.0% (range, 0–100%) among the 367 gen-
eral practice physicians in our sample, using the Spanish-
language OSAKA questionnaire compared with 73.4% among the
108 participants in internal medicine, pediatrics, and family med-
icine in the original study, using the English-language version
[17,18]. Mean knowledge scores significantly differed using v2
tests among physicians surveyed in Peru, Venezuela, and Ecuador
(Table 1). Cronbach a for the 18 items on the knowledge measure
was 0.58 using the Spanish-language version of the OSAKA com-
pared with a of 0.69 reported using binary data of the English-lan-
guage version [17].
Less than 50% of physicians correctly answered the questions
about the association between OSA and hypertension, uvulopalato-
pharyngoplasty as curative therapy in OSA, continuous positive
airway pressure (CPAP) therapy produces nasal congestion, women
with OSA may present with fatigue alone, and a collar size of 17
inches or larger is associated with OSA. Less than 30% of the phy-
sicians correctly answered that <5 apnea or hypopnea per hour is
normal in adults and that laser-assisted uvuloplasty is an appropri-
ate treatment for severe OSA (Table 1). We found no significant dif-
ferences in overall knowledge in gender or by time since
graduation (65 years vs >5 years).
There were differences among the participants in the three
countries in the proportions of correct answers to specific items
about the physician’s knowledge about OSA (Table 1). Lower pro-
portions of physicians in Ecuador compared with physicians in
Peru and Venezuela correctly answered the questions about uvulo-
palatopharyngoplasty being curative therapy for the majority of
patients with OSA, the relations between OSA and car accidents,
and between OSA and collar sizes of 17 inches or larger.
A lower proportion of physicians in Venezuela compared with
physicians in Peru and Ecuador correctly answered the question
about estimated prevalence of OSA. Lower proportions of physi-
cians in Venezuela compared with physicians in Peru and Ecuador
correctly answered the questions about CPAP producing nasal con-
gestion and about the prevalence of OSA. As shown, 5 of the 18
 I. Cherrez Ojeda et al. / Sleep Medicine 14 (2013) 973–977 975

Table 1
Proportion of correct answers to the knowledge items on the Obstructive Sleep Apnea Knowledge and Attitudes questionnaire, stratified by researched countries (N = 367).

OSAKA questions Total % Peru % Venezuela % Ecuador % P

N = 367 n = 93 n = 85 n = 189 value*
1. Women with OSA may present with fatigue alone 91.3 46.2 35.3 43.9 .28
2. Uvulopalatopharyngoplasty is curative for the majority of patients with OSA 88.8 51.6 56.5 32.8 <.001
3. The estimated prevalence of OSA among adults is between 2% and 10% 85.0 73.1 37.6 59.3 <.001
4. The majority of patients with OSA snore 85.0 84.9 92.9 88.9 .24
5. OSA is associated with hypertension 83.4 58.1 56.5 42.3 .02
6. An overnight sleep study is the gold standard for diagnosing OSA 81.2 84.9 71.8 18.9 .09
7. CPAP therapy may cause nasal congestion 77.1 42.5 17.6 36.5 <.001
8. Laser-assisted uvuloplasty is an appropriate treatment for severe OSA 65.1 22.6 18.8 16.4 .45
9. The loss of upper airway muscle tone during sleep contributes to OSA 62.7 89.2 87.1 78.8 .05
10. The most common cause of OSA in children is the presence of large tonsils and adenoids 59.7 95.7 88.2 90.5 .18
11. A craniofacial and oropharyngeal examination is useful in the assessment of patients with 57.8 88.2 87.1 82.5 .38
suspected OSA
12. Alcohol at bedtime improves OSA 49.6 81.7 83.5 79.9 .76
13. Untreated OSA is associated with a higher incidence of automobile crashes 43.1 65.6 78.8 54.0 <.001
14. In men a collar size 17 inches or greater is associated with OSA 42.5 38.7 49.4 29.6 .006
15. OSA is more common in women than men 36.5 68.8 69.4 61.4 .30
16. CPAP is the first therapy for severe OSA 34.3 69.9 61.2 54.0 .04
17. Less than 5 apneas or hypopneas per hour is normal in adults 25.3 31.2 21.2 24.3 .27
18. Cardiac arrhythmias may be associated with untreated OSA 18.5 83.9 88.2 84.1 .64
Mean total knowledge score 60.0 65.4 61.2 54.3 <.001

Abbreviations: OSAKA, Obstructive Sleep Apnea Knowledge and Attitudes questionnaire; OSA, obstructive sleep apnea; CPAP, continuous positive airway pressure.
*
Pearson v2 tests for comparisons of rates among the three surveyed countries.

items were correctly answered by less than 50% of participants
across all three of the studied countries.
Only a few of the knowledge items significantly differed by
number of years since medical school graduation. Among physi-
cians in Peru, a greater proportion of physicians who graduated
65 years ago correctly answered that laser-assisted uvuloplasty
is not an appropriate treatment for severe OSA compared with
the proportion of those >5 years after graduation (83.3% vs
46.9%; P = .018). Among physicians in Venezuela, a greater pro-
portion of physicians who graduated >5 years ago correctly an-
swered that a collar size of 17 inches or larger is associated
with OSA in men (55.2% vs 23.5%; P = .020). Among physicians
in Ecuador, a greater proportion of physicians who graduated
>5 years ago correctly answered the three questions related to la-
ser uvuloplasty (18.8% vs 0%; P = .009), loss of upper airway mus-
cle tone during sleep contributing to OSA (81.9% vs 63.0%;
P = .026), and alcohol at bedtime not improving OSA (81.9% vs
63.0%; P = .026), compared with physicians who graduated
65 years ago. However, total knowledge scores did not signifi-
cantly differ in number of years after medical school graduation
(65 years vs >5 years).
3.2. Attitudes
Among all respondents, 71.7% answered that OSA was an
important or an extremely important clinical disorder, and 73.3%
reported identifying patients at risk for OSA was important or ex-
tremely important. In addition, 73.5% of all physicians felt confi-
dent in identifying patients at risk for OSA. However, only 35.4%
felt confident in managing patients with OSA, and only 22.1% felt
confident in managing patients with CPAP therapy. Principal com-
ponents analyses of the five attitude items resulted in two factors,
and we compared our findings with the findings reported using the
original English-language version [17]. The internal consistency of
the two-item factor pertaining to the importance of OSA and its
diagnosis was high, with a Cronbach a of 0.86 (original version,
a = 0.92); this factor was similar in the internal consistency of
the three-item factor pertaining to physician confidence in identi-
fying and managing patients with OSA, with a Cronbach a of 0.74
(original version, a = 0.75). We also ran a factor analysis forcing
all five items on one factor, and our Cronbach a for these five items
was 0.69 (original version, a = 0.79). Spearman rank correlations
between knowledge total score and each of the attitudes items
were low (Table 2).
4. Discussion
OSA remains a highly underdiagnosed condition in the general
population. Furthermore, most primary care providers do not sys-
tematically screen patients for OSA and fail to identify comorbidi-
ties in high-risk patients [20,13,21]. In our study, we sought to
evaluate a Spanish-language version of the OSAKA questionnaire
[17] using a rigorous method of validation described by Sperber
[19]. We surveyed Latin American primary care physicians in three
South American countries regarding their knowledge of OSA and
its treatment and their attitudes about the importance of OSA
and their confidence in being able to identify and manage patients
with OSA. Our results should be interpreted within the context of
medical education of primary care physicians and with the consid-
eration of how the survey was developed and validated. Not only
did we follow a rigorous procedure outlined by Sperber [19] for
validating a translated version of a previously developed question-
naire, we also ran psychometric tests on the measures to compare
with reliability statistics reported by Schotland and Jeffe [17].
About one-third of the knowledge items, especially knowledge
about epidemiology, diagnosis, and treatment of OSA, were incor-
rectly answered by more than 50% of all general practice physician
respondents, regardless of the country where they were surveyed.
This finding indicates that both undergraduate and graduate med-
ical education coursework and clinical experiences should be
developed to augment training in the identification and manage-
ment of patients with OSA. However, more than 70% of surveyed
physicians felt confident in being able to identify patients at risk
for OSA, though only 35% felt confident in managing patients with
OSA. The low correlation between knowledge and confidence in
managing patients with OSA could reflect some self-protection bias
in physicians’ reporting about their confidence.
976 I. Cherrez Ojeda et al. / Sleep Medicine 14 (2013) 973–977
Table 2
Spearman correlation coefficients among mean scores of each attitude item, each attitude subscale, and total knowledge on the Obstructive Sleep Apnea Knowledge and Attitudes
questionnaire.
1 2
Importance of
1. OSA as a clinical disorder –
2. Identifying patients with OSA .76à
3. Importance of subscale score .95à .92à
Confidence in
4. Identifying at-risk patient .26à .26à
5. Managing patients with OSA .12* .09
6. Managing patients on CPAP .04 .00
7. Confidence subscale score .16  .13*
Total attitude and knowledge scores
8. Overall attitude score .55à .52à
9. Overall knowledge score .22à .17  .21à
Abbreviations: OSA, obstructive sleep apnea; CPAP, continuous positive airway pressure.
*
P < .05.
P < .01.
à
P < .001.
The Cronbach a for the Schotland and Jeffe [17] data was .69
using binary (correct/incorrect) responses to the 18 items. The
Cronbach a was .58 for the Spanish-language version of the OSAKA
using the binary data. Because we measured knowledge about OSA,
we could not expect to observe similar values across studies for
Cronbach a, which measures internal consistency of items on a
continuous measure and may be affected by the difficulty of the
test, the spread in scores, and the length of the examination. We
would not be expected to observe a similar Cronbach a for knowl-
edge if one sample had higher knowledge scores than another sam-
ple, which is what we observed when we compared the knowledge
scores for the Schotland and Jeffe [17] sample and for our Latin
American sample of physicians. The internal consistency of items
on this measure of knowledge also might have been affected by
characteristics of the testing situation (e.g., completion of a mailed
survey in private [17] compared with completion at a busy confer-
ence with potential distractions) or by characteristics of the indi-
vidual (e.g., fatigue, memory, attention).
The correlations between knowledge and importance of OSA
also were low and insignificant, which is similar to findings re-
ported in the original paper [17]. Because the Cronbach a for the
two attitudinal subscales (i.e., importance a = .86 and confidence
a = .74) were higher than the five-item factor (a = .69), we recom-
mend only using the two separate attitudinal subscales for future
research using the Spanish-language version of OSAKA, as the
two subscales measure different constructs which are not highly
correlated.
OSA is a risk factor for arterial hypertension; knowledge of this
risk was correctly reported by only approximately 50% of the phy-
sician participants in our study. This lack of physician knowledge
about an important clinical outcome of OSA could affect the diag-
nosis of arterial hypertension and increase the risk for later compli-
cations. A large proportion of general practice physicians who were
surveyed also believed that laser uvuloplasty was curative for se-
vere OSA, which is incorrect. Such beliefs could possibly delay
referral of patients to a specialist to initiate CPAP, which is the pre-
ferred treatment for patients with severe OSA. Therefore, the chal-
lenge for general physicians is not only to learn how to detect OSA
in patients who are at high risk for OSA, but also to either initiate
treatment or to refer these patients to specialists for further exam-
ination and treatment.
There also were differences in knowledge in the country where
among physicians were surveyed, with physicians surveyed in Peru
having higher total knowledge scores, especially in epidemiology
and adverse reactions from CPAP treatment compared to
3 4 5 6 7 8 9
.27à
.11* .50à
.02 .35à .59à
.15  .73à .87à .81à
.56à .72à .76à .66à .89à
.25à .25à .15  .27à .32à
physicians surveyed in Ecuador and Venezuela. It is unknown if
these differences in knowledge reflect differences in OSA education
in these three countries, as conference attendees were from vari-
ous countries.
Other studies have demonstrated that older physicians reported
lower adherence to treatment guidelines for patients with diabetes
mellitus [22], and another study found a negative correlation be-
tween years in practice and OSA knowledge using the OSAKA
[17]. However, we found no significant difference in total OSA
knowledge by years in practice (65 vs >5 years since graduation)
in our study. This phenomenon among the countries surveyed in
our study may reflect a lack of adequate information regarding
sleep disorders at the undergraduate and graduate medical educa-
tion levels. In addition, it also may reflect that this problem is the
same across countries.
We believe that Latin American medical schools and residency
programs need urgent attention to improve general practice physi-
cians’ knowledge of OSA to improve diagnosis and treatment of
this condition. Inadequate training among the primary care resi-
dency programs underlies the low levels of knowledge of the diag-
nosis and treatment of OSA [23]. Knowledge scores were
somewhat lower in our study than in the original OSAKA study
[17], with a mean 60.0% correct in our study compared with a
mean 73.4% correct using data from the original study (percentage
previously unpublished). This Spanish-language translation of the
OSAKA questionnaire was developed to help evaluate an educa-
tional intervention for residents who are trained in the diagnosis
and treatment of OSA, and it will be used to evaluate the results
of our training program. In addition, the OSAKA questionnaire
can be used to explore the knowledge of students who finish their
medical education to detect if there is a low knowledge about OSA
among recent medical graduates, and these results also could influ-
ence the development of sleep education programs at the level of
undergraduate medical education.
Our study had some limitations. First this was a cross-sectional
survey of general practice physicians attending conferences in
three South American countries. Thus, we cannot infer causation
from any of the associations we observed, and we also cannot gen-
eralize our results to Spanish-speaking physicians practicing in
other countries, as medical education about OSA might differ in
other Spanish-speaking countries in important ways. Indeed, we
observed significant differences in knowledge among physicians
surveyed in three Latin American countries in our study. Whether
or not physicians in other countries report similar or different
levels of knowledge about OSA using the OSAKA compared with
 I. Cherrez Ojeda et al. / Sleep Medicine 14 (2013) 973–977
physicians surveyed here is an empirical question which requires
further study. In addition, the general practice physicians who tra-
vel to medical meetings are likely to routinely attend educational
programs, and therefore these physicians might have more up-
dated medical knowledge than the larger group of general practice
physicians practicing in the community who do not attend contin-
uing medical education meetings. Thus, knowledge about OSA in
the larger population of general practice physicians is likely to be
even lower than the knowledge reported on our survey of medical
conference attendees. Another limitation is that 81% of the physi-
cians in our sample reported graduating >5 years ago; therefore,
we should be cautious in generalizing our results to physicians
with fewer years in practice after graduation. One respondent
who reported to be 21 years of age may have been a student; how-
ever, we included this individual’s data in the analysis, because
dropping these data from the analysis would not alter the direction
or significance of our findings. Additionally, even though knowl-
edge scores differed among the three countries, we cannot infer
that doctors who attended a conference in a particular country
were from that country or that they received their medical educa-
tion in the country where the conference took place.
Future studies are needed to determine the validity and reliabil-
ity of our translated OSAKA questionnaire in Latin American and
other Spanish-speaking physician populations. Incorporating
OSA-focused educational interventions during medical school and
residency training programs should help to improve physicians’
knowledge about OSA as well as the detection and treatment. Latin
American pulmonology societies should offer sleep disorder ses-
sions at continuing medical education conferences and create
OSA education programs for general physicians such as those that
currently exist for asthma or chronic obstructive pulmonary
disease.
Conflict of interest
The ICMJE Uniform Disclosure Form for Potential Conflicts of
Interest associated with this article can be viewed by clicking on
the following link: http://dx.doi.org/10.1016/j.sleep.2013.06.005.
Acknowledgment
We express our gratitude and acknowledgment to MECOR-ATS
Program Director A. Sonia Buist M.D, MECOR Latin-American Pro-
gram Director Ana Maria Menezes M.D.; and the MECOR Faculty:
Sandra Wilson, PhD; Bill Vollmer, PhD; Juliana Ferreyra M.D; and
David Gonzalez PhD for their contribution to the development of
the study.
We want to thank to Dr. Edwin Soria and Dr. Luis Espinoza from
Southern Medical Corporation (CorpSur) for their support in data
collection as well as Andrea Fernandez, Gabriela Sanchez, Jazmin
977
Sanchez, and Andres Rodriguez (Respiralab) for their aid in data
collection and the data entry process.
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