A secondary analysis of the role of geography in engagement and outcomes in a clinical trial of an efficacious Internet intervention for insomnia

Abstract

BackgroundOnline interventions for insomnia can increase access to treatments for those with limited access to services. What remains unknown is whether individuals from more isolated (vs. more densely populated) regions engage with, and benefit as much from, an online intervention. This secondary analysis examined the relationship of geographical indices with engagement and outcomes of an efficacious, fully automated online cognitive behavioral therapy for insomnia (CBT—I) program (Sleep Healthy Using the Internet-SHUTi).Method303 participants (Mage = 43.3; SD = 11.6) were randomly assigned to SHUTi or an online patient education condition and assessed at baseline and post intervention. Rural code of participants was determined using participant zip codes. Distance to the nearest sleep medicine provider was calculated as the distance between the center of the nearest provider's city (from a publicly available list of CBT-I providers) and the center of the participants' zip code. Adherence outcomes were number of intervention core completions, sleep diaries, and logins. Sleep outcomes were insomnia severity as well as sleep onset latency and wake after sleep onset derived from online sleep diaries.ResultsIndividuals were from a range of geographic locations. Most lived in fairly densely populated areas; however, there was a large variation in distance to the nearest sleep medicine provider. Findings indicate that the efficacy, adherence, and engagement with SHUTi were not impacted by where people lived. Controlling for age and gender did not impact any of the relationships among geography variables (i.e., distance, ruralness) and adherence or sleep related outcomes.ConclusionsInternet interventions must demonstrate that they can overcome obstacles posed by geography. This is the first study to examine the geographic location of participants and its association with engagement with, and outcomes of, online CBT-I.

Effects of an internet-delivered insomnia intervention for older adults: A secondary analysis on symptoms of depression and anxiety

“…Sleep Healthy Using the Internet (SHUTi) is one such fully-automated CBT-I program, which has been demonstrated effective in treating insomnia and addressing comorbid symptoms across various populations both with and without medical and psychiatric comorbidities (Christensen et al, 2016 ; Luyster et al, 2018 ; Moloney et al, 2020 ; Ritterband et al, 2017 ; Zachariae et al, 2018 ). Delivering CBT-I by the Internet has several benefits, including: reducing geographical inequities in access to this care, addressing the significant gap in demand to available clinicians, and being more cost-effective than delivering care by a clinician (Chow et al, 2019 ; De Bruin et al, 2016 ; Thomas et al, 2016 ). These benefits are of particular importance for older adults, given that older adults comprise a larger share of the population in rural areas relative to suburban or urban areas (Pew Research Center, 2018 ), and behavioral sleep medicine providers are less available in rural areas (Chow et al, 2019 ; Thomas et al, 2016 ).…”

“…Delivering CBT-I by the Internet has several benefits, including: reducing geographical inequities in access to this care, addressing the significant gap in demand to available clinicians, and being more cost-effective than delivering care by a clinician (Chow et al, 2019 ; De Bruin et al, 2016 ; Thomas et al, 2016 ). These benefits are of particular importance for older adults, given that older adults comprise a larger share of the population in rural areas relative to suburban or urban areas (Pew Research Center, 2018 ), and behavioral sleep medicine providers are less available in rural areas (Chow et al, 2019 ; Thomas et al, 2016 ). Also, fully-automated Internet interventions are private, which helps reduce the barrier of stigma to accessing care.…”