Barriers and facilitators to implementing a stepped care cognitive-behavioral therapy for insomnia in cancer patients: a qualitative study

Abstract

Purpose: Insomnia affects 30-60% of cancer patients and tends to become chronic when left untreated.While cognitive-behavioral therapy for insomnia (CBT-I) is the recommended rst-line treatment, this intervention is not readily accessible. This qualitative study investigated current practices in the assessment and management of insomnia in ve hospitals offering cancer care and identi ed the barriers and facilitators to the implementation of a stepped care CBT-I (i.e., web-based CBT-I followed, if needed, by 1-3 booster sessions) in these settings.Methods: Nine focus groups composed of a total of 43 clinicians (e.g., physicians, nurses, technologists, psychologists), six administrators, and 10 cancer patients were held. The Consolidated Framework for Implementing Research (CFIR) was used to develop the semi-structured interview and analyze the data.Results: Sleep di culties are not systematically discussed in clinical practice and when a treatment is offered, most often, it is a pharmacological one. Barriers and facilitators to the implementation of a stepped care CBT-I included individual characteristics (e.g., lack of knowledge about CBT-I); intervention characteristics (e.g., increased accessibility offered by a web-based format); inner setting characteristics (e.g., resistance to change); and process factors (e.g., motivation to offer a new service).Conclusions: This qualitative study con rms the need to better address insomnia in routine cancer care and suggests that, while some barriers were mentioned, the implementation of a stepped care CBT-I is feasible. Keys to a successful implementation include accessibility, training, inclusion of stakeholders in the process, and ensuring that they are supported throughout the implementation.

Focus Group Study of Heart Failure Nurses’ Perceptions of the Feasibility of Cognitive Behavioral Therapy for Insomnia

“…Another possibility is implementing a stepped care delivery model, as proposed by Espie (2009), whereby participants receive one of five levels of CBT-I started with the least intensive and increased in “steps” based on need when first level of care is insufficient. Interventions targeted to the severity of insomnia or insomnia refractory to initial intervention may also be useful (Manber et al, 2015; Savard et al, 2022), cost-effective, and favored by participants (Koffel et al, 2021). Although these approaches are under investigation (Manber et al, 2022; Spiegelhalder et al, 2022), to our knowledge, no studies have addressed these approaches among adults with chronic HF.…”

The association between sleep problems and general quality of life in cancer patients and in the general population

“…This message is not new, but the compilation of the studies with different cancer types and different settings confirms the generalizability of this finding. Since sleep problems can become chronic when left untreated, health care providers should consider offering their patients who suffer from sleep problems intervention techniques for improving sleep quality such as physical exercise (Yang et al, 2021), behavioral or cognitive-behavioral treatment (Zhou et al, 2020;Savard et al, 2022), or stress reduction (Suh et al, 2021).…”

Editorial: Sleep and circadian rhythms in cancer patients and their relationship with quality of life

“…Moreover, additional studies of sleep and circadian rhythms are needed in relation to cancer treatments beyond chemotherapy, such as endocrine- and immune therapies, with the former being proposed to most breast cancer patients for at least 5 years and that may also impact cognitive functioning (Wu and Amidi, 2017 ). Finally, there is an increasing number of interventional studies targeting sleep problems or aiming to improve circadian rhythms in cancer patients being published (Garland et al, 2014 ; Wu et al, 2018 , 2022 ; Savard et al, 2022 ). Future investigations will hopefully determine the optimal approach to administer cancer treatments informed by circadian biology, such as tailoring the timing of treatments to individuals' chronotype (e.g., Innominato et al, 2022 ; Printezi et al, 2022 ).…”