Project Summary/Abstract: The burden of stroke remains unacceptably high and few treatments are proven to improve stroke prevention or recovery. An estimated 70% to 90% of stroke survivors have obstructive sleep apnea (OSA). Compared to those without OSA, stroke patients with OSA have worse functional outcomes after inpatient rehabilitation (IPR), 40% longer IPR stays, a 100% increase in the risk of non-fatal cardiovascular events, particularly recurrent stroke, and a 75% increase in the risk of early death. Observational data suggest that treatment with continuous positive airway pressure (CPAP), the first-line treatment for OSA, holds promise to improve stroke outcomes, including both preventing recurrence and improving recovery. However, poor CPAP adherence has compromised pilot trials of stroke survivors with OSA, yielding mixed results and limiting the ability to test CPAP efficacy. Individualized behavioral interventions to improve CPAP adherence have shown benefit in the general population, though little is known about their effectiveness to optimize CPAP among stroke patients, who are likely to respond to behavioral interventions differently. We propose to adapt and refine for stroke patients a multicomponent behavioral intervention to improve CPAP adherence with the engagement and input of stroke survivors. Then, within a multicenter randomized controlled trial, we will test the efficacy of the intervention, initiated during inpatient rehabilitation, on CPAP use among stroke patients over the course of 3 months. The adherence intervention will include: 1) CPAP technical support, 2) motivational enhancement therapy, and 3) self-monitoring using mobile health technologies with automated support. If successful, the study will provide researchers a much-needed intervention to realize the full benefits of CPAP after stroke. It is difficult to imagine a non-invasive, relatively low-cost intervention with a similar potential as CPAP for such a common and disabling a disease as stroke.