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Behavior Therapy 45 (2014) 430 442
www.elsevier.com/locate/bt
431
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screening measures
Insomnia Severity Index
The ISI was used as a brief screening measure of
insomnia, and as an indicator of treatment outcome
2 weeks after one session of behavioral insomnia
treatment. The ISI is a valid and reliable tool that
quantifies perceived sleep difficulties and insomnia
severity (Morin, 1993; Morin, Belleville, Blanger,
& Ivers, 2011). It is a seven-item instrument with
ratings on a 0- to 4-point scale. A total composite
score is summed with higher scores indicating greater
insomnia severity. A clinical cutoff score of 8 was
used as an identifier of threshold insomnia because it
has optimal sensitivity and specificity in distinguishing people with insomnia from normal sleepers
(Savard, Savard, Simard, & Ivers, 2005).
ICSD-II Insomnia Screener
Participants responded to questions about ICSD-II
criteria for probable insomnia. The questions were
During the past 4 weeks did you have difficulty
falling asleep, staying asleep, waking up too early,
or feeling poorly rested in the morning? and Did
you have trouble sleeping despite having adequate
opportunity and circumstances to sleep? Response
choices for both questions included never,
sometimes, usually, or always. Participants
independent variables
Potential Daily Assessed Predictors
All day-to-day factors were measured using an
online sleep diary (Perlis, Jungquist, Smith, &
Posner, 2005). Participants were asked to record
immediately prior to bed how they felt during the
day on the following variables: pain, fatigue, mood,
stress, perceived health status, amount of daily
exercise (in minutes), and number of alcoholic
beverages consumed. Pain and fatigue severity were
measured on a 05 scale from none to a lot. Mood
(affect) was assessed on a 05 scale from bad to
good. Perceived health status was measured on a 05
scale from felt fine to bad. Total sleep time, sleep
efficiency, and sleep quality (i.e., very poor, poor,
fair, good, or excellent) were recorded immediately
after the final awakening of each night.
Potential Baseline Predictors
Baseline, self-reported variables included perceived
health status, treatment-related self-efficacy, acceptance of treatment, intentions to adhere, ISI score,
GSAQ-measured excessive daytime sleepiness,
GSAQ-measured depressive and anxiety symptoms,
and frequency of sleeping with a bed partner or pet.
See Table 1 for an overview of how most of these
variables were measured. Treatment-related selfefficacy was measured with one item adapted from
Reed and Aspinwall (1998). The item read, If I
wanted to follow treatment recommendations it
would be easy for me to do so tonight, and was
measured on a 19 scale from totally disagree to
totally agree. Acceptance of treatment and intentions to adhere were assessed with the following
adapted questions from Sherman and colleagues
(2000): How important do you think it is that
people engage in the sleep-promoting behaviors
that were discussed to avoid the consequences of
poor and limited sleep? and How likely do you
think it is that you personally will actually follow
433
adherence measures
Adherence to sleep recommendations was measured with online sleep diaries and two adherence
logs specific to SH and SCT instructions. Sleep
diaries are a record of a participants sleep and
wake time each night for a period of 2 weeks. The
sleep diary used in the present study was by Perlis
and colleagues (2005). This particular diary was
used because it documents common sleep variables
and specific variables related to SCT and SRT
instructions. The primary dependent variable from
the sleep diary was the average of the time deviations
(in minutes) from the prescribed wake time. This
average was used as a measure of adherence to SRT.
This method is similar in approach to that by Riedel
and Lichstein (2001) who found that this method of
assessing SRT adherence through variations in
arising time is superior to other adherence measures in predicting treatment outcome. Specifically
they found that measures of time in bed and
bedtime reduction did not significantly correlate
with treatment outcomes, whereas lower variance
in arising time in the morning was significantly
correlated.
Two adherence logs were used to document
whether the participants were adherent to the six
instructions of SCT and the five instructions of
SH. The proportion of instructions the participants were compliant to each of the 14 days was
averaged. This method of measurement is similar
to that used in a previous study (McChargue et
al., 2012).
procedure
Didactic sessions were conducted in a university
building by a trained undergraduate honors research
assistant who was supervised on a weekly basis by a
certified behavioral sleep medicine specialist. Sessions were conducted at various times across the
2010 2011 academic year, but never between
semesters or during spring break. Each session was
delivered in an interactive, didactic format to small
groups of two to nine participants. The sessions were
not structured as group therapy. The treatment
session featured sleep and insomnia education, and
three behavioral treatment components: SCT, SRT,
and SH. The session lasted 1.5 hours. After the
treatment session, participants completed 14 days of
time-stamped, online sleep and adherence diaries. To
dampen any bias in the measurement of the studys
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Table 1
# Log Entries
Mean or %
SD
Range
1.7
1725
Baseline Variables
Age (years)
Gender (% female)
Race/ethnicity
Non-Hispanic White
Non-Hispanic Black
Other Ethnic groups
Health status
Good, fair, or poor
Excellent or very good
Insomnia Severity Index
GSAQ excessive daytime sleepiness
Usually or always
Never or sometimes
Bed partner or pet frequency
At least sometimes
Never
GSAQ depressive or anxiety symptoms frequency
Usually or always
Never or sometimes
Self-efficacy
Low (15)
Moderate (67)
High (89)
Acceptance of treatment
Lower (57)
Higher (89)
Intentions to adhere
Lower (37)
Higher (89)
53
46
18.9
86.8
40
10
3
75.5
18.9
5.7
22
31
53
41.5
58.5
12.4
3.4
8.021.0
18
35
34.0
66.0
23
30
43.4
56.6
20
33
37.7
62.3
18
19
16
34.0
35.9
30.1
30
23
56.6
43.4
27
26
50.9
49.1
# Log Entries
Mean or %
SD
Range
700
700
719
109
610
719
521
198
719
161
373
185
719
66
284
369
720
367
353
719
493
159
67
407.4
86.4
3.4
15.2
84.8
0.9
72.5
27.5
2.6
22.4
51.9
25.7
3.3
9.2
39.5
51.3
2.4
51.0
49.0
1.1
68.6
22.1
9.3
130.0
15.0
0.4
1.2
1.3
-
0857
0100
1.94.5
05
05
-
1.2
-
05
-
1.4
1.4
-
05
05
-
435
# Log Entries
Mean or %
SD
Range
35.9
1.37
0300
09
Baseline Variables
718
718
631
87
24.8
0.6
87.9
12.1
Note. GSAQ = item derived from the Global Sleep Assessment Questionnaire; SD = standard deviation
Data Analysis
We computed descriptive statistics on all predictor
variables, covariates, and outcomes. A paired-samples t test was used to compare baseline and
posttreatment ISI scores. The continuous data for
the adherence outcome measures were not normally
distributed; therefore, they were collapsed into
ordinal variables. The average proportion of SCT
instructions followed over the 14-day follow-up
period was categorized into the following groups:
less than four out of six (b 0.67); four out of six
(0.67); five out of six (0.83); and six out of six
(1.00). The average proportion of SH instructions
followed over the 14-day follow-up period was
categorized into the following groups: 0.80; 0.80
0.90; and 1.00 (five out of five instructions). The
average deviation in minutes from the prescribed
wake time in SRT was converted into clinically
meaningful increments as follows: 0; 115; 1630;
3145; 4660; 6190; and N 90.
A proportional odds model (Scott, Goldberg &
Mayo, 1997) using generalized estimated equations
was used to analyze the ordinal outcome data and
produce odds ratios (ORs) and 95% confidence
intervals (CIs) for the association between the
baseline and daily assessed predictors with SCT,
SRT, and SH adherence scores. The use of
generalized estimated equations allowed for the
models to account for the clustering within study
participants. Daily assessed fatigue, mood, stress,
pain, sleep quality, and health status as well as
baseline self-efficacy, treatment acceptance, and
436
Results
sample characteristics
Fifty-three participants completed the treatment
protocol and at least 9 days of sleep diaries and
adherence logs (M = 13.2, SD = 1.8, range: 9
14 days). Five additional participants completed
the treatment protocol but dropped out of the study
before providing any sleep diary or adherence log
information. These participants were significantly
older, M = 20.8, SD = 2.7 versus M = 18.9, SD =
1.7, t(56) = 2.3, p = .030, and had less treatmentrelated self-efficacy, M = 4.4, SD = 2.9 versus M =
6.3, SD = 1.8, t(56) = 2.1, p = .040, than the final
sample. They did not differ on any other baseline
variables. The most cited reason for dropping out
of the study was time commitment. The vast
majority of the final sample were full-time students
(98.1%), and 15.4% were employed part-time.
None of the participants reported being diagnosed
or treated for a mental disorder. Descriptive
statistics on all independent variables can be
found in Table 1.
treatment outcome
Baseline ISI scores (M = 12.4, SD = 3.4) compared
with 2-week follow-up ISI scores (M = 10.7, SD =
3.7) indicated a statistically significant reduction in
insomnia severity, t(50) = 3.51, p = .001.
missing data
Common to most studies conducting daily measurements, there were some missing data on the
daily assessed variables and adherence measures.
Missing data for the daily assessed variables from a
possible 742 entries (i.e., 53 participants 14 days)
ranged from 3.0 to 5.7%. Missing data for the daily
adherence measures ranged from 3.2 to 4.2%. Given
the small percentages of missing data, complete case
analyses were not employed to assess all relationships.
# Log
Entries
Mean
or %
SD
Range
719
106
168
309
136
713
0.77
14.7
23.4
43.0
18.9
81.6
0.18
96.5
01
0540.0
207
71
55
22
62
55
241
720
122
247
351
29.0
10.0
7.7
3.1
8.7
7.7
33.3
0.85
16.9
34.3
48.8
0.18
01
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Stepwise Approach to Final Model of Variables Associated With Adherence to Stimulus Control Therapy
Step 1: Retain Effects at p b .20
a
95% CI
Domain
Predictor
OR
Health (ref: excellent or very good; 01); good, fair, or poor (24)
Self-efficacy (ref: high; 89);
moderate (67)
Low (15)
Bed partner or pet (ref: never)
Total sleep time (15-min increments)
Sleep efficiency (5% increments)
Sleep quality (ref: fair to excellent); poor to very poor
Pain (ref: none to low; 01);
moderate to high (25)
Health status (ref: good; 01);
fair health (23)
Poor health (45)
Exercise (30-min increments)
1.79
0.70
0.22
2.06
0.95
1.14
0.57
1.46
0.60
0.45
1.16
0.94, 3.41
0.31, 1.59
0.09, 0.55
1.14, 3.69
0.92, 0.98
1.03, 1.27
0.34, 0.98
1.02, 2.09
0.43, 0.85
0.23, 0.87
0.96, 1.41
Health (ref: excellent to very good; 01); good, fair, or poor (24)
Self-efficacy (ref: high; 89);
moderate (67)
Low (15)
Bed partner or pet (ref: never)
Total sleep time (15-min increments)
Sleep efficiency (5% increments)
Sleep quality (ref: fair to excellent); poor to very poor
Pain (ref: none to low; 01);
moderate to high (25)
Health status (ref: good; 0-1);
fair health (23)
Poor health (45)
1.68
0.66
0.21
2.06
0.95
1.14
0.57
1.47
0.58
0.44
0.93,
0.33,
0.10,
1.14,
0.92,
1.03,
0.34,
1.01,
0.40,
0.24,
3.03
1.31
0.44
3.69
0.98
1.27
0.98
2.15
0.84
0.83
.085
.235
b .001
.016
.003
.007
.043
.043
.004
.011
0.79
0.25
2.57
0.95
1.14
0.56
0.39,
0.13,
1.53,
0.92,
1.03,
0.33,
1.58
0.46
4.33
0.98
1.25
0.94
.512
b .001
b .001
.003
.009
.006
Daytime symptoms
Daytime behaviors
.077
.392
.001
.016
.003
.007
.043
.041
.004
.018
.134
Daytime symptoms
Final Model With All Significant Predictors (p b .05) in Step 3: From All Domains
Baseline treatment perceptions
moderate (67)
Low (15)
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Table 4
Stepwise Approach to Final Model of Variables Associated With Adherence to Sleep Restriction Therapy
Step 1: Retain Effects at p b .20
Domain
Predictor
OR a
95% CI
Nightly sleep
0.78
1.51
0.46
0.70
0.62
0.39
0.72,
1.34,
0.29,
0.49,
0.40,
0.22,
0.83
1.70
0.74
0.99
0.96
0.70
b .001
b .001
.001
.043
.033
.002
0.78
1.51
0.46
0.68
0.59
0.38
0.72,
1.34,
0.29,
0.47,
0.37,
0.21,
0.83
1.70
0.73
0.99
0.93
0.68
b .001
b .001
.001
.049
.023
.001
0.77
1.53
0.46
0.38
0.72,
1.36,
0.29,
0.17,
0.83
1.72
0.74
0.84
b .001
b .001
.001
.017
Daytime symptoms
Daytime behaviors
Daytime symptoms
Daytime behaviors
Final Model With All Significant Predictors (p b .05) in Step 3: From All Domains
Nightly sleep
Daytime behaviors
Discussion
Daily variations in adherence, during the 2 weeks
after one session of behavioral therapy for insomnia,
were associated with several pretreatment participant
factors and during treatment state factors. Lower
baseline treatment-related self-efficacy was related to
lower SCT and SH adherence. Sharing a bed with a
partner or pet was related to better SCT adherence.
Poor sleep quality, greater total sleep time, and less
sleep efficiency were associated with poorer SCT and
SRT adherence the following night. Consumption of
alcoholic beverages was related to poorer SRT and
SH adherence on the following night.
The association between low self-efficacy and
poorer adherence to SCT and SH recommendations is in concordance with a previous study. That
study found that greater global, treatment-related
self-efficacy was related to better weekly adherence
to cognitive-behavioral therapy for insomnia,
particularly during the first week of treatment
(Bouchard et al., 2003). In the present study,
self-efficacy accounted for more of the variability
439
Stepwise Approach to Final Model of Variables Associated With Adherence to Sleep Hygiene Recommendations
Step 1: Retain Effects at p b .20
p
1.10
1.94
0.58
0.58
1.28
0.40
1.67
0.67
0.50
0.61
0.11
0.96,
0.84,
0.26,
0.27,
0.46,
0.12,
0.79,
0.37,
0.30,
0.30,
0.06,
1.25
4.47
1.32
1.25
3.51
1.34
3.54
1.20
0.80
1.23
0.20
.189
.121
.195
.162
.637
.138
.181
.173
.004
.167
b .001
1.11
0.31
0.75
0.51
0.64
0.11
0.42,
0.12,
0.34,
0.30,
0.32,
0.07,
2.95
0.81
1.66
0.87
1.26
0.19
.827
.016
.480
.014
.194
b .001
0.93
0.25
0.11
0.38, 2.30
0.10, 0.63
0.06, 0.21
.882
.004
b .001
Predictor
OR
95% CI
Domain
moderate (67)
Low (15)
Sleep quality (ref: fair to excellent); poor to very poor
Health status (ref: good 01);
fair health (23)
Poor health (45)
Alcohol (ref: 0 drinks)
Final Model With All Significant Predictors (p b .05) in Step 3: From All Domains
Baseline treatment perceptions
Daytime behaviors
moderate (67)
Low (15)
440
Conclusions
We discovered several pretreatment participant
factors as well as daily experienced factors during
treatment engagement were related to daily variations in adherence to a brief behavioral intervention
for insomnia. The results suggest interventions
designed to enhance self-efficacy in conjunction
with behavioral therapies for insomnia may be
worthy of further testing, particularly if this finding
is replicated in future studies. We recommend that in
research and clinical settings, the presence of another
person or pet in the bedroom ought to be assessed to
determine whether it may be an important factor in a
given patients treatment engagement and response.
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