STRENGTHS AND LIMITATIONS OF THIS STUDY

A structured questionnaire was developed by the authors specifically to collect knowledge, attitude and practice towards insomnia and sleep hygiene in patients with insomnia.

The study was conducted in a region known for the notable gap between the diagnosis and treatment of insomnia and included a relatively large sample size.

A single-centre sample may introduce bias, and a cross-sectional design prevents the determination of causality.

Although exploratory factor analysis and confirmatory factor analysis showed the acceptable construct validity of the questionnaire, those validation processes were performed after questionnaire collection.

Reliance on self-reported data, particularly from online questionnaires, might raise validity concerns.

Background

Chronic insomnia disorder includes individual difficulties in starting or continuing sleep for at least 4 weeks and various health and functional impairments related to prolonged sleep latency, early morning awakening and inability/difficulty to maintain sleep.1 2 Insomnia is approximately 1.5 times more common in women than in men,3 with a prevalence of 10%–40% in the general population.4 5 In 2017, the prevalence of chronic insomnia in the general population in China reached 15%, reaching 35.9% in individuals aged>60 years.6 Chronic insomnia disorder is known to have negative effects on cognitive, emotional and interpersonal functions. However, proper treatment is rarely addressed, leading to adverse effects on the central nervous, endocrine and cardiovascular systems, thereby aggravating sleep disorders and leading to a vicious circle.4 7

Sleep hygiene education (SHE) is among the most common treatments for insomnia.8 However, according to the American Academy of Sleep Medicine clinical practice guidelines,9 SHE alone is often insufficient as a treatment for chronic insomnia disorder. Therefore, other ways should be sought to improve the treatment effect. Besides SHE, effective non-pharmacological therapies include cognitive–behavioural therapy (CBT) and behavioural interventions. Still, higher costs and a lack of trained specialists often lead doctors and patients to choose pharmacological interventions.10 At the same time, almost no decisive evidence is available regarding pharmacological therapy’s effectiveness, safety and appropriate duration.11 Although insomnia has attracted a great deal of attention from public health and sleep medicine experts, the phenomenon of chronic insomnia itself is not fully explained by classical medical theory. A notable gap exists between diagnosis and treatment, in part because those who are sleepless rarely discuss the problem with medical experts who have the authority to diagnose insomnia.2 12 Therefore, the absence of reliable diagnostic and treatment information often results in miscommunication between doctors and patients with chronic insomnia.

Knowledge, attitude and practice (KAP) surveys are a useful tool for investigating health-related behaviours and health-seeking practices.13 That methodology was previously used to analyse the sleep difficulties in the general population during COVID-1914 or interest in sleep-inducing medicine among medical students.15 Although influencing the KAP of patients may help to improve their lifestyle and increase their awareness of the disease and their positive response to treatment, to the authors’ knowledge, there are few KAP studies among patients with insomnia, and no recent KAP study was conducted among patients with chronic insomnia in China.

Therefore, this study aimed to investigate the KAP towards insomnia and sleep hygiene among patients with chronic insomnia and explore self-reported symptoms associated with KAP and sleep hygiene-related behaviour in Northwest China.

MethodsStudy design and participants

This cross-sectional study included patients with insomnia between August 2022 and October 2022 at Shaanxi Provincial People’s Hospital. The inclusion criteria were (1) age 20–70 years, (2) insomnia diagnosis and (3) voluntary participation. Insomnia was either newly diagnosed onsite according to the International Classification of Sleep Disorders—third edition16 or self-reported by the patient as difficulty initiating sleep, maintaining sleep continuity or poor sleep quality. The exclusion criteria were (1) participants with psychiatric disorders, (2) participants with cognitive impairment, (3) participants with auditory or visual impairment, (4) participants who participated in other studies within the last 30 days, (5) participants who did not complete the questionnaires within the specified time or (6) participants who requested to withdraw from this study. All questionnaires were anonymised once questionnaire collection was completed. The responses on the paper questionnaires were entered into the database (double-entry method). The paper questionnaires were destroyed once data entry was validated. The database was kept on a secured server that was accessible only through proper identification.

Questionnaire

The questionnaire was designed based on a recent study on sleep-related practices among the urban-dwelling African American community17 and revised according to a study on patients with chronic insomnia in Beijing,18 the Guidelines for the diagnosis and treatment of insomnia disorders in China19 and the guidelines on conducting KAP studies.13 After the initial design, the questionnaire was reviewed by two experts. Any items deemed uncertain, incorrect or inappropriate for the study population were carefully examined and subsequently removed to uphold the content validity of the questionnaire. A pilot study was conducted among 50 participants, and Cronbach’s α was 0.807, indicating good internal consistency. During the pilot study, the participants were administered the questionnaire and asked to identify items with unclear or confusing descriptions. Any items flagged as such were carefully examined, and the researcher provided clarifications as necessary. No items remained ambiguous or confusing after clarification, indicating a good face validity of the questionnaire.

The final questionnaire (online supplemental materials) was in Chinese. The questionnaire (online supplemental materials) contained four dimensions: demographic information (age, gender, ethnicity, occupation, residence, marital status, income level, smoking and drinking and comorbidities), knowledge dimension, attitude dimension and practice dimension. The knowledge dimension consisted of 12 questions, with 1 point for a correct answer and 0 for a wrong or unclear answer, with a score range of 0–12. The attitude dimension consisted of 14 questions using a 5-point Likert scale ranging from strongly agree to strongly disagree. Questions 1, 7, 9 and 14 were assigned 1 point for strongly agree and 5 for strongly disagree, and the other questions scored 5 points for strongly agree and 1 for strongly disagree, with a score range of 14–70. The practice dimension contained 14 questions using a 5-point Likert scale ranging from always/strongly agree (5 points) to never/strongly disagree (1 point), with a score range of 14–70. The overall KAP was described as low, moderate and high, according to Bloom’s method (using 60% and 80% of the total scores as cut-off).20

The participants were enrolled through convenience sampling when they visited Shaanxi Provincial People’s Hospital for sleep-related disorders. Throughout the study period, individuals visiting the hospital for regular check-ups who met the inclusion criteria and expressed interest were provided with information about the objectives of the study. In order to mitigate selection and non-response biases, participants who were volunteering for this study were given the option to complete the questionnaire either online through a QR code, via the ‘Wenjuanxing’ platform, or onsite using a paper questionnaire, depending on their preference and convenience. At the end of the study, the investigators conducted thorough checks to identify and address any instances of questionnaire repetition or duplication, ensuring the integrity and accuracy of the dataset. Questionnaires with missing responses were excluded.

Sample size calculation

The sample size was calculated using a single population proportion formula based on the assumption that the probability of having low KAP scores was 50.0%, at 95% CI, 5% margin of error, and determined to be at least 384.20

Statistical analysis

Statistical analysis was performed using SPSS V.26.0. Continuous data were described as means±SD and compared using the independent-sample t-test (between two groups) or one-way analysis of variance (ANOVA) (among three or more groups). Categorical data were described as n (%). A post hoc test for construct validity was conducted using Kaiser-Meyer-Olkin (KMO) analysis and confirmatory factor analysis (CFA). Pearson’s method was used to analyse the correlation between KAP scores. The KAP scores were categorised into better/poorer according to 75% of the total participants, and multivariable logistic regression was used to explore the factors independently associated with participants’ KAP. The data with p<0.05 in the univariable analysis were included in the multivariable analysis. Structural equation modelling (SEM) was used to test the hypotheses that (H1) knowledge regarding insomnia and sleep hygiene affects attitudes, (H2) knowledge affects practices and (H3) attitude affects practices. A two-sided p<0.05 was considered a statistically significant difference.

Patient and public involvement

Patients and the public were not involved in designing or conducting the study. The results will be disseminated to the patients as part of the consultations for sleep disorders at the authors’ hospital.

Results

A total of 613 valid questionnaires were collected, meeting the sample size requirement. The post hoc test for construct validity showed a KMO=0.838, and the CFA indicated the questionnaire fits the KAP model well (online supplemental figure 1 and table 1). Most respondents were married (78.63%), had no comorbidities (73.57%), received secondary education or above (66.23%) and were smokers (56.61%).

The Mean Knowledge Score was 7.63±2.56 (total score 12), the Mean Attitude Score was 48.39±6.643 (total score 70) and the Mean Practice Score was 42.37±8.592 (total score 70). Significant differences in knowledge were found among respondents of different ages, education, occupations, incomes and comorbidities. There were significant differences in attitude found among respondents with different ages, marital status and comorbidities, while significant differences in practice patterns were found among respondents with different ages and education (all p<0.05) (table 1).

Table 1

Baseline characteristics, knowledge, attitude and practice towards insomnia and sleep hygiene

In the knowledge dimension, most respondents (571, 93.1%) were not aware that chronic insomnia was hard to cure, and less than half of all respondents (196, 32%) were aware that chronic insomnia could be treated by means other than medication (online supplemental table 2). In the attitude dimension, most patients agreed (262, 42.7%; 309, 50.4%) or strongly agreed (221, 36.1%; 157, 25.6%) that insomnia had affected their physical health, mood and concentration. Only 123 (20.1%) and 38 (6.2%) of the respondents felt or strongly felt that they were still leading a satisfactory life despite suffering from insomnia (online supplemental table 3). In the practice dimension, about half of the respondents (296, 48.3%) wanted to know more about insomnia treatment. About half of the respondents (295, 48.1%) reported often and always practising short-term day sleeping; when facing sleep difficulties, most patients (415, 67.7%) preferred to lie in bed and try to fall asleep, and when persistent insomnia occurred, most patients (448, 73.1%) never or occasionally took medication (online supplemental table 4).

The correlation analysis (table 2) showed that knowledge significantly correlated with attitude (r=0.447, p<0.001) and practice (r=0.327, p<0.001), while respondents’ attitudes significantly correlated with practice (r=0.486, p<0.001).

Table 2

Correlation analysis

The multivariable logistic regression analysis showed that higher education level (OR=1.836 (1.149–2.933), p=0.011), comorbidities (OR=0.542 (0.342–0.861), p=0.009), occupation (office employees and related personnel vs professional technical personnel, OR=2.009 (1.226–3.292), p=0.006) and income (¥) (vs <2000, 2000–5000: OR=0.461 (0.270–0.787), p=0.005; 5000–10000: OR=0.181 (0.095–0.345), p<0.001; >20 000: OR=0.347 (0.124–0.973), p=0.044) were independently associated with better knowledge (table 3). Comorbidities (OR=0.593 (0.372–0.946), p=0.028) and better knowledge (OR=1.338 (1.220–1.468), p<0.001) were independently associated with better attitudes (table 4). Only better knowledge (OR=1.181 (1.062–1.314), p=0.002) and better attitude (OR=1.171 (1.124–1.221), p<0.001) were independently associated with better practice (table 5).

Table 3

Multivariable analysis for characteristics associated with knowledge

Table 4

Multivariable analysis for characteristics associated with knowledge, attitude and practice

Table 5

Multivariable analysis for characteristics associated with knowledge, attitude and practice

SEM was used to explore the factors influencing practice (online supplemental figure 2 and table 5). It was found that knowledge had a direct positive effect on attitude (β=1.160, p<0.001) and practice (β=0.457, p<0.001), while attitude had an additional effect on practice (β=0.550, p<0.001).

Discussion

This study found moderate KAP scores towards insomnia and sleep hygiene among patients with chronic insomnia in China in 2023. The knowledge scores were associated with the attitude scores, while the knowledge and attitude scores were associated with the practice scores. To the authors’ knowledge, the present study is the first on KAP towards insomnia in China, and the results obtained might provide a new basis for non-pharmacological treatment of insomnia and be used to develop and implement new treatment modalities.

Sleep problems have become a worldwide concern, but the diagnosis and treatment of chronic insomnia in China have a notable gap, especially in the usage of CBT.6 21 In order to address the above issue, some specific dimensions on which data were previously unavailable are covered in this study, using consistent data collection techniques according to the sample size. Despite moderate KAP scores, some questions demonstrated worrisome trends in the study population. Over half of the respondents needed at least 8 hours of sleep to be energetic during the day. Still, less than 10% believed that chronic insomnia could be actively cured, and most respondents (67.7%) reported lying in bed when experiencing sleeping difficulties without taking any other actions. Notably, only 6.2% of the respondents fully believed that they could live a satisfying life despite sleep difficulties, indicating that most participants believed that insomnia affects quality of life. Although many variables were associated with knowledge and attitude, the multivariable analysis showed that only knowledge and attitude affected practice, which is in line with some previous reports.8 15 Those results suggest that education on the cognition and treatment of insomnia in the general population still needs to be strengthened, including specific related to the diagnosis of insomnia, the cure rate of insomnia, treatment methods (especially non-pharmacological treatment methods), the impact of insomnia on physical and mental health. Nevertheless, education was independently associated with knowledge level, with junior college students or undergraduates having a higher level of education but showing more negligence towards sleep hygiene practice,22 23 suggesting that an advanced approach is needed to influence practice patterns through education.

It was previously reported that chronic insomnia disorder is often associated with metabolic abnormalities (amino acid, glucose and lipid metabolism), other psychiatric disorders and medical conditions.4 10 In this study, although most participants had no comorbidities, the comorbidity status was independently associated with higher knowledge and attitude scores without any significant effect on the practice scores. It might be partly because participants with comorbidities pay more attention to insomnia or receive related information from the doctor.24 25 In contrast, others tend to believe that sleeping difficulties are related to stress or life habits. Thus, comorbidities or hospitalisation not only increases the risk of sleep disturbances caused by disease-related, environmental, psychological and social factors23 24 but also might affect the level of knowledge and attitude of the patients, which should be considered in future studies.

One of the noteworthy findings in this study is that practice was significantly influenced by knowledge, both directly and indirectly, through attitude, suggesting that a lack of adherence to sleep hygiene might be at least partly related to the lower knowledge of the existing management options. Current general practice guidelines recommend CBT for chronic insomnia disorder as a first-line treatment. However, previous studies noted that general practitioners often prescribe hypnotic or sedative drugs.26–28 In China, the pharmacological treatment of insomnia is not popular among physicians and patients, as confirmed by the present study, where most patients (448, 73.1%) did not take any medication even if persistent insomnia occurred. It should be noted that patients with insomnia in China sometimes use Traditional Chinese Medicine, such as acupuncture or acupressure.29 30 Although reported to be safe and effective, those methods were not included in the present study’s questionnaire. In addition, CBT is not popular in China, mostly because the scope of the treatment is difficult to achieve in primary care. In this study, only 6.9% of participants believed that chronic insomnia disorder can be cured, which is a relatively small number. Potential solutions could include strengthening education about effective insomnia treatments, creating referral pathways to specialist services, or introducing brief (and thus more available) CBT.27 31

This study has some limitations. First, all patients with insomnia included in the study were from a single centre, potentially introducing bias and limiting the generalisability of the findings to the broader population of northwest China. Moreover, there could be additional regional peculiarities specific to the location of the study centre. Second, this study was cross-sectional, with certain limitations regarding drawing conclusions and analysing causal relationships. Although exploratory factor analysis and CFA showed the acceptable construct validity of the questionnaire, the procedure was performed after the questionnaire collection. The exact number of paper questionnaires distributed and the number of times the QR code was scanned were not recorded, and the response rate could not be calculated. Finally, answers in this study were self-reported and could not be checked, which might have led to the differences between reported and actual behaviour. Finally, some of the questionnaires were distributed online among participants who had been diagnosed elsewhere. Although the results might be used to plan further educational interventions, the noted limitations should be considered.

In conclusion, KAP towards insomnia and sleep hygiene among patients with chronic insomnia in Northwest China in 2023 is moderate, with better practice showing signs of being influenced by better knowledge, both directly and indirectly through attitude. The findings emphasise the importance of improving the knowledge of the specific population through advocacy and education to improve attitude and practice levels. Specifically, the findings revealed that pharmacological treatment for insomnia remains underutilised in China, and only 6.9% of participants believed that chronic insomnia could be cured. Based on these observations, enhancing education on effective insomnia treatments is paramount. Moreover, establishing referral pathways to specialist services and introducing brief and readily accessible CBT should be considered. By prioritising education and awareness-raising efforts, coupled with the implementation of accessible treatment modalities, such initiatives will improve individual treatment outcomes and contribute to broader public health strategies to reduce the burden of insomnia on society.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplemental information.

Ethics statementsPatient consent for publication

Not applicable.

Ethics approval

This work has been carried out in accordance with the Declaration of Helsinki (2000) of the World Medical Association. This study was ethically approved by the ethical review board of the Shaanxi Provincial People’s Hospital ((2023) No. (R047)). Participants gave informed consent to participate in the study before taking part.