Internet-Based Cognitive Behavioral Therapy for Insomnia in Appalachian Women: A Pilot Study.

OBJECTIVE/BACKGROUND: Appalachian women are disproportionately affected by insufficient sleep but live in a healthcare shortage area with prevalent prescription drug abuse. A self-administered, non-pharmacologic intervention such as Internet-based cognitive behavioral therapy for insomnia (CBT-I) may be ideal in this population, but psycho-social characteristics (e.g., high depression rates) and cultural norms (e.g., suspicion of technology) necessitate a pilot study. We evaluated the effectiveness of Sleep Healthy Using the Internet (SHUTi) on insomnia severity, sleep quality, perceived stress, depression symptoms, and sleep aid use in Appalachian women ages 45 +. PARTICIPANTS: Forty-six women enrolled; 38 completed the six-week intervention in 2018 (mean age 55 years). METHODS: We employed a single group, pre/post-test, mixed-methods design. Participants completed an online survey and a qualitative interview pre- and post-intervention. Quantitative data were analyzed using one-way repeated measures ANOVA or generalized estimating equations. Interviews were qualitatively analyzed using a multi-stage coding process. RESULTS: Positive and statistically significant (p < .01) improvements were observed on mean scores for the Insomnia Severity Index (15.1 to 6.5), the Pittsburgh Sleep Quality Index (12.1 to 8.5), the Perceived Stress Scale (20 to 14.6), and the Center for Epidemiologic Studies Depression Scale Revised (9.8 to 5.2). The odds of reporting sleep medication use post-intervention were significantly lower than pre-intervention (OR 0.28 [95% CI 0.11-0.74]). Interviews highlighted most and least helpful intervention components and suggested that participants benefitted from SHUTi. CONCLUSIONS: Internet-based CBT-I may be a useful, non-pharmacologic treatment that reduces insomnia severity, perceived stress, depression symptoms, and sleep aid use in middle-aged Appalachian women.

Improvement in Post-traumatic Stress Symptoms Following an Internet-based Cognitive-Behavioral Intervention for Insomnia: An Open Trial among Rural Appalachian Women.

Appalachian women face significant health disparities and have limited access to health care. Mental health conditions and treatment-seeking are stigmatized in Appalachian communities. Appalachian women may benefit from web-based interventions targeting less stigmatized health complaints (e.g., insomnia), while simultaneously yielding benefit in associated mental health conditions including symptoms of post-traumatic stress disorder (PTSD). In this study, 37 trauma-exposed adult women aged 45 and older from rural Appalachian Kentucky completed a six-session online self-administered cognitive behavioral therapy for insomnia (CBT-I) intervention and completed measures of PTSD symptoms, insomnia, and depression at pre- and post-treatment. Participants reported a significant reduction in PTSD symptoms from pre- to post-intervention, and this remained significant after adjusting for severity of insomnia and depression pre-treatment. Pending replication in a randomized controlled trial, web-based CBT-I may offer an adjunctive mental health treatment option that circumvents cultural stigmas and reduces PTSD symptoms for trauma-exposed Appalachian women.

Effects of a digital cognitive behavioral therapy for insomnia on sleep and alcohol consumption in heavy drinkers: A randomized pilot study.

BACKGROUND: Insomnia is a well-established, prospective risk factor for Alcohol Use Disorder. Thus, targeting sleep problems could serve as a novel and efficacious means of reducing problematic drinking. Here, we examined the potential utility of a well-validated, interactive, easy to use, self-paced digital cognitive behavioral therapy for insomnia program. In a randomized, single-blind pilot study, we examined the impact of treatment with Sleep Healthy Using the Internet (SHUTi) on drinking and sleep outcomes in a sample of heavy drinkers with insomnia. METHODS: Heavy drinking men (n = 28) and women (n = 42) with insomnia were randomly assigned to complete either the SHUTi program or a control patient education program. Subjective measures of sleep and alcohol use were administered at baseline, immediately following completion of the intervention, 3 months post-intervention, and 6 months post-intervention. Sleep outcomes were assessed using the Insomnia Severity Index and Pittsburgh Sleep Quality Index. Drinking outcomes were assessed using the 30-Day Timeline Follow-Back calendar. We used linear mixed effects models to compare groups on both insomnia and drinking outcomes. RESULTS: Data from all 70 subjects (SHUTI: n = 40; control: n = 30) were analyzed. Linear mixed effects models showed that SHUTi significantly reduced insomnia symptoms (p = 0.01) and drinking outcomes (ps < 0.05) more than the control condition over time. Trend-level effects on sleep quality (p = 0.06) were also observed. No adverse events were reported. CONCLUSIONS: Improving sleep may be an effective treatment intervention for reducing hazardous drinking in at-risk individuals. Further, findings provide preliminary support for the implementation of an easily accessible health behavior intervention with significant public health impact in a high-risk population.

Sex Differences in the Association Between Poor Sleep Quality and Alcohol-Related Problems Among Heavy Drinkers With Insomnia.

Background: Alcohol Use Disorder (AUD) and insomnia are highly comorbid; at least 40% of individuals with AUD suffer from insomnia. Women are more likely to report insomnia than men and have seen a concerning rise in rates of AUD in recent years. As such, the association between AUD and insomnia could be particularly pronounced in women. However, currently little is known regarding sex differences in this association. Here we examined the degree to which relationships between alcohol use and sleep quality differ between women and men. Methods: Heavy drinking women (n = 66) and men (n = 45) completed the Pittsburgh Sleep Quality Index (PSQI) to assess sleep quality and the Alcohol Use Disorders Identification Test (AUDIT) to assess alcohol use and alcohol-related problems. Hierarchical regression analyses were conducted to determine sex differences in the association between poor sleep quality and alcohol-related problems. Results: After controlling for age, global subjective stress, and depression, sex significantly moderated the positive association between poor sleep quality and alcohol-related problems. Further analyses of the simple slopes for each sex revealed that poorer sleep quality (i.e., higher scores on the PSQI) were associated with greater alcohol-related problems (i.e., higher scores on the AUDIT) in women, but not in men. Conclusion: These results suggest that in heavy drinkers with insomnia, poor sleep is more strongly associated with drinking problems in women than in men. Future research is needed to investigate potential mechanisms underlying this relationship. Specifically, it will be important to determine whether sleep problems in heavy drinking women are a cause or consequence, or both, of heavy drinking.

Alcohol use, sleep, and depression among family caregivers in the time of COVID-19.

The COVID-19 pandemic has substantially altered daily life around the world, resulting in significant impacts on health behaviors. The additional burdens imposed by family caregiving (i.e., providing unpaid care for children and/or adults) may further exacerbate negative effects of the pandemic on health and health behaviors, including increased alcohol consumption, poor sleep, and increased depressive symptoms. The current study examined this possibility. Participants (N = 320, mean age = 35.11 years) completed an online questionnaire assessing alcohol use, sleep, and depression during the COVID-19 pandemic (June-August 2020) and retrospectively assessed the same health behaviors in the months prior to the pandemic. Insomnia severity increased, sleep quality decreased, and depressive symptoms increased for both caregivers and non-caregivers during the pandemic (p < 0.001). By contrast, alcohol consumption increased among caregivers only (p < 0.05). Further, increased alcohol use was associated with decreased sleep quality and increased insomnia symptoms among caregivers, but not non-caregivers. While additional longitudinal research is warranted in this population, our findings offer important insight on self-reported changes in alcohol consumption, sleep patterns, and mood among family caregivers during the COVID-19 pandemic.

Preterm Birth Prevention in Appalachia: Restructuring Prenatal Care to Address Rural Health Disparities and Establish Perinatal Health Equity.

Purpose: This perspective piece reflects off previously published qualitative work to explore (1) themes surrounding equitable prenatal care in Appalachia and (2) strategies to restructure care delivery in a population with disparate rates of preterm birth (PTB). Methods: This study reflects in-depth interviews with 22 Appalachian women who experienced PTB and 14 obstetric providers. Results: Our findings underscore the need for greater cultural humility in prenatal care, heightened awareness of social determinants of health, and strategic planning to establish equity in birth outcomes. Conclusion: Prenatal care must undergo a paradigm shift to include a comprehensive discussion of cultural humility, social disparities, and health equity.

Appalachian Women's perspectives on preterm birth and transvaginal ultrasound cervical length screening: Implications for addressing disparities in preterm birth.

PURPOSE: Preterm birth (PTB), a pressing issue for US maternal-child health, disproportionately impacts women in Appalachia. Transvaginal ultrasound (TVU) cervical length (CL) screening is the most accurate PTB risk predictor but remains underutilized. This study characterizes the knowledge, attitudes and beliefs of patients with prior PTB concerning PTB prevention efforts and TVU CL screening. METHODS: Participants were recruited from community-based health centers in Appalachian Kentucky. Semi-structured interviews and likert-scale surveys were conducted with 22 pregnant women with a history of spontaneous PTB. Methods for data collection were guided by the Consolidated Framework for Implementation Research (CFIR). RESULTS: Most participants reported that TVU was uncomfortable, but none refused it. Most women were able to articulate the benefits of TVU, but several had concerns about its safety in pregnancy. Participants suggested that pregnant women receive more PTB education and self-advocate. They urged providers to take patient concerns seriously, and better educate patients on PTB risks and TVU safety. DISCUSSION: Our study contributes crucial insights about the experience of a vulnerable population as it pertains to PTB prevention and the uptake of TVU CL screening. Our findings emphasize the need for increased efforts to better educate patients on the impact of prematurity and the safety and benefits of TVU CL screening as an evidence-based strategy for PTB prevention.

Preterm Birth Prevention in Appalachian Kentucky: Understanding Barriers and Facilitators Related to Transvaginal Ultrasound Cervical Length Surveillance Among Prenatal Care Providers.

Background: Appalachian Kentucky has higher-than-average rates of preterm birth (PTB)-a health disparity associated with increased maternal and fetal/neonatal morbidity and neonatal mortality. Transvaginal ultrasound (TVU) cervical length measurement is the best predictor of PTB risk, but is underutilized in Appalachia. This study explores prenatal care providers' TVU-related knowledge and practices, and identifies barriers and facilitators, which impact the adoption of this evidence-based technology. Materials and Methods: This study recruited providers from three Appalachian Kentucky health care sites. Prenatal care providers took part in semistructured interviews and completed brief survey scales. Questions focused on PTB knowledge, TVU-related barriers, and suggestions for clinician and/or patient-focused interventions. Transcripts were coded using a multistage process based in grounded theory. Descriptive statistics were calculated. Results: Eleven physicians, one nurse practitioner, one physician assistant, and one midwife completed interviews. Average participant age was 44 years with 17 years in practice; 43% of providers were female. Practitioners described the sociodemographic characteristics, health behaviors (e.g., smoking, opioid abuse), and comorbid conditions (e.g., obesity, hypertension, and diabetes) endemic in Appalachia that heightened their patients' PTB risk. TVU use was reported as important by all respondents, but not all were satisfied with their level of training. The most commonly identified barriers to TVU were patient access to transportation and social support. Participants stressed a need for changing community perceptions regarding consequences of PTB. Conclusions: Providers identified multiple TVU-related barriers and facilitators. These data will inform the design of a multifaceted dissemination and implementation strategy targeting PTB prevention in Appalachia.