Insomnia is a prevalent sleep disorder associated with numerous adverse health outcomes, including fatigue, irritability, and impaired daytime functioning. Despite the availability of effective pharmacological and psychological treatments, relatively few individuals with insomnia seek professional help, highlighting the need for accessible and acceptable non-pharmacological interventions. Sleep hygiene education (SHE) has the potential to address this gap due to its simplicity, low cost, and ease of self-administration. Building on our previously registered pilot-testing protocol, this study aims to examine the effectiveness of a theory-based SHE program integrated with behavior change techniques in a larger community population. Furthermore, it remains unclear whether theory-based SHE is inferior to gold-standard interventions such as cognitive behavioral therapy for insomnia (CBT-I) delivered via digital applications. Therefore, this study will also compare the effectiveness of theory-based SHE with a CBT-I app using a three-arm randomized controlled trial design.
Insomnia is a prevalent sleep disorder associated with substantial adverse health consequences, including fatigue, irritability, and impaired daytime functioning. Although effective pharmacological (e.g., hypnotics) and psychological treatments (e.g., cognitive behavioral therapy for insomnia, CBT-I) are available, both local and international surveys indicate that fewer than 50% of individuals with insomnia seek treatment. This treatment gap underscores the need for effective non-pharmacological interventions that are both accessible and acceptable. Sleep hygiene education (SHE) represents a potentially suitable approach to address this unmet need. SHE is an educational intervention encompassing a range of lifestyle and environmental recommendations to optimize sleep quality and duration. These include maintaining a regular sleep-wake schedule, avoiding substances such as caffeine, nicotine, and alcohol, limiting daytime napping and stimulating activities before bedtime, optimizing the sleep environment, and adopting appropriate dietary and exercise habits etc. Given its simplicity, low cost, accessibility, and ease of delivery and adoption, SHE holds promise as a non-pharmacological strategy for insomnia management. Despite these advantages, SHE is not typically recommended as a stand-alone treatment for individuals with sleep problems, as it is often perceived to be less effective than CBT-I or mindfulness-based interventions, with consistently small effect sizes reported. However, these findings should be interpreted with caution. In many previous studies, SHE has primarily been used as a passive control condition to account for nonspecific treatment effects, thereby underexploiting its active therapeutic potential. Moving SHE beyond a simple advice-giving modality to a structured, theory-informed approach may optimize its effectiveness by ensuring its content is informative and promising. Integrating SHE with established behavior change techniques may better equip individuals with the skills needed to initiate and sustain meaningful behavioral change. Building on our previously registered pilot-testing protocol, this study aims to evaluate the effectiveness of a theory-based SHE program integrated with behavior change techniques in a larger community sample. In addition, it remains unclear whether theory-based SHE is inferior to gold-standard interventions such as digitally delivered CBT-I. This study will also examine whether a theory-based SHE program is a cost-effective approach for reducing insomnia severity in adults with insomnia disorder compared with a CBT-I app and a no-intervention control. To address these objectives, a three-arm randomized controlled trial will be conducted to compare the relative effectiveness of these interventions.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
DOUBLE
Enrollment
264
Participants in this group will receive a structured six-week SHE intervention. The intervention includes two weekly 2-hour group-based, face-to-face educational sessions (total 4 hours) conducted in a classroom at the School of Nursing, The Hong Kong Polytechnic University, followed by four weekly individualized telephone consultations lasting approximately 10 minutes each. During the educational sessions, participants will receive education on insomnia and evidence-based sleep hygiene practices, and will develop individualized behavior change plans to support sustained implementation of sleep hygiene practices. The subsequent telephone consultations will reinforce adherence to these plans by reviewing progress, discussing barriers, and providing tailored feedback.
Participants in this group will receive a CBT-I program consisting of six weekly modules delivered in the Chinese language through a smartphone application proACT-S. The duration of each module is around 45 to 60 min with interactive features. The self-help CBT-I treatment content in proACT-S is based on the Chinese translated version of a well-established CBT-I treatment manual. The self-help CBT-I treatment content is designed to alter dysfunctional cognitive beliefs and maladaptive behaviors that perpetuate insomnia. The self-help CBT-I treatment content CBT-I aims at changing dysfunctional cognitive beliefs and maladaptive behaviors that contribute to the maintenance of insomnia.
School of Nursing, The Hong Kong Polytechnic University
Hong Kong, Hong Kong
The Insomnia Severity Index (ISI)
The Insomnia Severity Index has 7 items that measured the severity of insomnia complaints and related daytime impairments. The total score ranges between 0 and 28, with the higher scores indicating more severe insomnia. Total score will be used.
Time frame: Baseline, week 6, week 12 and week 24
Sleep Onset Latency Measured By Sleep Diary
Participants will be asked to record their daily sleeping-waking schedule using a standard sleep diary. Sleep onset latency (SOL) is defined as the time (minutes) taken to fall asleep after going to bed. The average value over 7 consecutive nights will be calculated.
Time frame: 7 consecutive nights before each assessment time point (i.e., baseline, week 6, week 12, and week 24)
Wake After Sleep Onset Measured By Sleep Diary
Participants will be asked to record their daily sleeping-waking schedule using a standard sleep diary. Wake after sleep onset (WASO) is defined as the total time (minutes) awake after initial sleep onset during the night. The average value over 7 consecutive nights will be calculated.
Time frame: 7 consecutive nights before each assessment time point (i.e., baseline, week 6, week 12, and week 24)
Sleep Efficiency Measured By Sleep Diary
Participants will be asked to record their daily sleeping-waking schedule using a standard sleep diary. Sleep efficiency (SE) is defined as the percentage of time in bed spent asleep. The average percentage over 7 consecutive nights will be calculated.
Time frame: 7 consecutive nights before each assessment time point (i.e., baseline, week 6, week 12, and week 24)
Total Sleep Time Measured By Sleep Diary
Participants will be asked to record their daily sleeping-waking schedule using a standard sleep diary. Total sleep time (TST) is defined as the total duration (minutes) of sleep per night. The average value over 7 consecutive nights will be calculated.
Time frame: 7 consecutive nights before each assessment time point (i.e., baseline, week 6, week 12, and week 24)
The Hospital Anxiety and Depression Scale (HADS)
The Hospital Anxiety and Depression Scale is a self-report rating scale of 14 items on a 4-point Likert scale (range 0-3). It is designed to measure anxiety and depression (7 items for each subscale). The total score is the sum of the 14 items, and for each subscale the score is the sum of the respective seven items (ranging from 0-21).
Time frame: Baseline, week 6, week 12 and week 24
The Short-Form Six Dimensions (SF-6D)
The Short-Form Six Dimensions (SF-6D) will be used to assess the quality of life. The score ranges from 0 (worst quality of life) to 1 (perfect quality of life), with higher scores reflecting better overall health-related quality of life.
Time frame: Baseline, week 6, week 12 and week 24
Sleep Onset Latency Measured By Actigraphy
Sleep onset latency (SOL) will be objectively measured using a wrist-worn actigraphy device (GENEActiv, Activinsights, UK). Participants will wear the device on their non-dominant wrist for 7 consecutive nights prior to each assessment time point. SOL will be recorded in minutes, and the mean value over the 7-night period will be calculated.
Time frame: 7 consecutive nights before each assessment time point (i.e., baseline, week 6, week 12, and week 24)
Wake After Sleep Onset Measured By Actigraphy
Wake after sleep onset (WASO) will be objectively measured using a wrist-worn actigraphy device (GENEActiv, Activinsights, UK). Participants will wear the device on their non-dominant wrist for 7 consecutive nights prior to each assessment time point. WASO will be recorded in minutes, and the mean value over the 7-night period will be calculated.
Time frame: 7 consecutive nights before each assessment time point (i.e., baseline, week 6, week 12, and week 24)
Sleep Efficiency Measured By Actigraphy
Sleep efficiency (SE) will be objectively measured using a wrist-worn actigraphy device (GENEActiv, Activinsights, UK). Participants will wear the device on their non-dominant wrist for 7 consecutive nights prior to each assessment time point. SE will be expressed as a percentage, and the mean value over the 7-night period will be calculated.
Time frame: 7 consecutive nights before each assessment time point (i.e., baseline, week 6, week 12, and week 24)
Total Sleep Time Measured By Actigraphy
Total sleep time (TST) will be objectively measured using a wrist-worn actigraphy device (GENEActiv, Activinsights, UK). Participants will wear the device on their non-dominant wrist for 7 consecutive nights prior to each assessment time point. TST will be recorded in minutes, and the mean value over the 7-night period will be calculated.
Time frame: 7 consecutive nights before each assessment time point (i.e., baseline, week 6, week 12, and week 24)
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