Background
The theoretical domains framework (TDF)
Methods
Literature search and study identification
Application of the TDF framework to identified studies
Results
Clinician factors
Authors (Year) [Ref] | Country (community/cohort) | Study population | Measures | Main findings | TDF Domain(s) |
---|---|---|---|---|---|
Orr et al. (1980) [37] | United States | 378 Physicians attending a course on sleep disorders | Examination of popular misconceptions of sleep (20 Questions) | Physicians scored below chance suggesting a greater need for sleep medicine education as part of training. | Skills |
Hohagen et al. (1993) [38] | Germany | 2512 patients attending 10 general practitioners | Questionnaire at 3 time points: baseline (T1), 4 months later (T2), 2-years later (T3), included DSM criteria | In 8.8% of cases of mild insomnia, 21.9% of cases of moderate insomnia and 39.2% of cases of severe insomnia the GP was aware of a sleep problem. 5% of insomnia cases were diagnosed without the patient reporting a sleep problem in the questionnaire. | Knowledge, Skills |
Hohagen et al. (1994) [39] | Germany | 330 older adults (aged 65+) attending 5 general practitioner clinics | DSM-III-R criteria | In 18% of cases of mild insomnia, 31% of cases of moderate insomnia and in 52% of cases of severe insomnia the GP was aware of a sleep problem. 14% of insomnia cases were diagnosed without the patient reporting a sleep problem in the questionnaire. | Knowledge, Skills |
Haponik et al. (1996) [40] | United States | 20 experienced primary care practitioners, 23 uninstructed medical interns and 22 interns with instruction on sleep medicine | Frequency of sleep history recorded during encounters with simulated patients (30 min consultations) | Interns who had received instruction in sleep medicine more often asked about sleep (81.8%), but uninstructed interns (13%) and physicians (0%) did not record sleep history during consultation. | Knowledge, Belief about capability |
Papp et al. (2002) [41] | United States (Northeast Ohio) | 105 physicians | Structured survey on attitudes and knowledge of sleep disorders | Physicians rated their knowledge of sleep disorders as ‘fair’ (60%) and ‘poor’ (30%). Only 10% rated their knowledge as good, and 0% rated it as excellent. | Knowledge, Skills, Professional Role and Identity, |
Greatest influence on changing practice style regarding sleep were journal articles followed by continuing education, followed by discussion with specialists. | |||||
Siriwardena et al. (2010) [42] | United Kingdom (Lincolnshire, rural cohort) | Cross-sectional study of GPs (n = 84) | Prescribing preferences of GPs for insomnia vs anxiety diagnoses | For insomnia, GPs were more likely to favour giving advice on sleep hygiene and prescribing a hypnotic (Z-drugs favoured over benzodiazepines). For anxiety, referral to a psychologist/mental health worker was favoured. | Beliefs about capabilities, Environmental context and resources |
Preference to reduce use of drugs for insomnia but GPs felt insufficient resources or alternative management strategies were available | |||||
Hassed et al. (2012) [22] | Australia, Melbourne (metropolitan sample) | 15 General Practitioners | Focus groups (n = 7) and face-to-face interviews (n = 8). DSKQ | Scores from DSQK suggested gaps in knowledge related to defining the underlying cause and correct treatment options. | Knowledge, Skills, Environmental context and resources |
Behavioural intervention were viewed as preferable to prescribing medication. | |||||
Barriers to knowledge identified: limited training, lack of resources, patient expectation to receive a pill, consultation time constraint. | |||||
Cheung et al. (2014) [43] | Australia, Sydney (metropolitan sample) | GPs (n = 8) Pharmacists (n = 14) | Semi-structured interview from a convenience sample. Data analysed using a framework analysis | Practitioners perceived an overreliance on pharmacotherapy and inadequate support to direct patients to alternate pathways. | Environmental context and resources |
Patients often have a reliance or expectation of a ‘quick fix’. | |||||
Conroy & Ebben (2015) [44] | University of Michigan Hospitals and Weill Cornell Medical College of Cornell University. | Physicians (n = 239) | Questionnaire –mailed out | Most physicians did not nominate CBTi or a hypnotic as the most effective treatment for insomnia. | Knowledge, Skills |
1/3 recommended sleep hygiene. | |||||
N = 22 felt CBTi alone was effective. | |||||
Davy et al., (2015) [45] | Primary care in Nottinghamshire and Lincolnshire. | Health professionals (n = 23), and patients with insomnia (n = 28) | Focus groups, and interviews | Practitioners tended to focus on sleep hygiene rather than CBTi. | Knowledge, Skills, Behavioural Regulation |
Some practitioners felt they colluded with patients when prescribing hypnotics. | |||||
Patients often ignored sleep hygiene advice, and sometimes took hypnotics as not intended | |||||
Both practitioners and patients wanted more options and better training |
Patient factors
Authors (Year) | Country (town and community) | Study population | Measures | Main findings | TDF Domain(s) |
---|---|---|---|---|---|
Kushida et al. (2000) [18] | United States (Idaho, rural cohort) | Primary care patients seen at the clinic over a 1 year period (1997–1998) n = 1249, all 18+. (participation rate 60.1% 1254/2087) | Questionnaires (focused on sleep disordered symptoms for insomnia, RLS, OSA), ESS, SF-36 – daytime functioning (face-to-face or mail-out/ Interviews | 32.3% had insomnia (29.7% of men and 34.5% of women). | Knowledge, Skills |
14.1% experienced insomnia on a nightly basis. | |||||
State that patients have limited access to sleep specialists and a lack of training for physicians | |||||
Aikens & Rouse (2005) [36] | United States (Urban population) | N = 700 consecutive attendees at primary care, screened for insomnia. 326 mailed a follow-up survey to which n = 180 responded | Questionnaires assessing insomnia, sleep quality, and daytime consequences of sleepiness and fatigue (ISI, PSQI, ESS, DBAS, MFIS) | Of the 180 responders, 72% had probable insomnia. Those who had discussed it with their physician (52% of those with probable insomnia) reported poorer overall health Those who were more educated, had >co-morbid symptoms, lower TST or > daytime dysfunction more likely to discuss | Knowledge, Behavioural regulation, Beliefs about consequences. |
Morin et al. (2006) [4] | Canada, Quebec Province. | 2001 French speaking adults aged 18+. Mean age 44.7 | Telephone survey with insomnia defined as per the DSM-IV and the ICD-10 | 29.9% reported insomnia symptoms. | Behavioural regulation, Beliefs about consequences. |
13% had consulted a healthcare professional about their insomnia. | |||||
15% had used a herbal product, 11% a prescribed sleep medication, 3.84% an OTC drug and 4.1% alcohol to manage insomnia. | |||||
Daytime fatigue, psychological distress and physical discomfort were symptoms prompting individuals to seek treatment. | |||||
Bartlett et al. (2008) [6] | Australia, New South Wales, (mixed urban-rural) | Postal survey of 10,000 people randomly selected from the electoral roll (5000 aged 18–24 and 5000 aged 25–64). 3300 responded. Direct contact with a random subset of non-responders (n = 100) was undertaken (response rate of 49%) by telephone. | Postal survey and direct contact. Survey included AIS and ESS. | Population weighted prevalence of insomnia = 33% and in 74.7% of these the complaint has been present for > 12 months. | Behavioural regulation, Beliefs about consequences. |
Population weighted prevalence of a visit to a doctor for insomnia = 11.1% | |||||
Risk factors for insomnia were: older age, daytime sleepiness, short sleep duration (< 6.5 h), reduced enthusiasm. | |||||
Self-medication for insomnia was common but often satisfaction with treatment was poor. For prescription drugs 39% of users were satisfied compared with 16% for OTC drugs and 25% for herbal products. | |||||
Bailes et al. (2009) [27] | Canada (Montreal, city cohort) | N = 191 older patients (aged 50+) in primary care. n = 138 from 2 hospital-based sleep clinics (new referrals aged 18+). | Sleep Symptom Checklist- 21 items (insomnia, sleep disorders, daytime symptoms and psychological distress) they had discussed with their physician in the past year. | Primary care patients often have sleep symptoms they do not discuss, or discuss non-specifically. | Knowledge |
Subsequent PSG with primary care participants | |||||
Those referred to the sleep clinic were more likely to have discussed sleep problems (also younger and more males) | |||||
Those who completed PSG more likely to report sleep symptoms compared with those who completed questionnaire only. | |||||
Dyas et al. (2010) [9] | UK (Lincolnshire, rural cohort | Patients (who had sought help for insomnia in the previous 6 months) | Focus groups/ semi-structured interviews separate for patients (n = 30, 11 M, 19 F, aged 25–70) | Patients felt a need to convince professionals of their health problems. | Beliefs about capabilities, Environmental Context and Resources |
Patients often suffered for long periods before seeking help, and had tried self-help methods | |||||
Patients recognised sleep problems were linked to detrimental outcomes. | |||||
Clinicians noted multiple causes of sleep problems | |||||
Clinicians often focused on underlying causes rather than addressing treatment or consequences of non-treatment. | |||||
Omvik et al. (2010) [46] | Norway | Epidemiological postal survey (n = 5000). Mean age 48.1. | Sleep medication prevalence and reasons for use questions | Prevalence of sleep medication use: Lifetime = 18.8%, Current = 7.9% and Chronic = 4.2%. | Social influences |
Bergen Insomnia Scale, Global Sleep Assessment Questionnaire, Structured Clinical Interview for DSM., WHOqoL, SDS | Sleep medication use associated with low SES, older age, female gender, frequent sleep and/or mood disturbance. | ||||
Among those who had ever used a sleep medication, 80.3% would prefer a non-drug treatment. | |||||
Senthilvel et al. (2011) [19] | United States (Cleveland Ohio, urban population) | New adult patients aged 18–65 (n = 101) 52% female, mean age = 38 years | CSHQ, Berlin, ESS, STOP, review of GP records of the consultation | 30% of cases = possible insomnia, but limited screening and sleep history obtained during the consult | Environmental Context and resources |
Bjorvatn et al. (2017) [15] | Norway | Patients visiting their GP (n = 1346), 35.9% Male | BIS, Self-reported sleep problems (1-item), insomnia (DSM-IV criteria), hypnotic use | BIS insomnia rate = 53.6%, sleep problems (single item) = 55.8%. | Knowledge, Skills |
Hypnotics used by 16.2% (daily use was 5.5%). |
Discussion
Clinician factors
Features | Classification | Clinical note(s) | Further classification or notes |
---|---|---|---|
Duration of symptoms | |||
Acute/Short-term (ICD-3) | Symptoms last < 3 months | Typically lasts 1 night to a few weeks. May result from illness or a circadian rhythm disturbance such as jet-lag | |
Chronic (ICD-3)/Insomnia disorder (DSM-5) | Symptoms last > 3 months | Usually trouble sleeping is reported 3+ nights for > 3 months | |
Timing | |||
Onset | Falling asleep takes > 30 min | ||
Maintenance | Interruptions lasting more than 30–45 min are experienced during the night | ||
Early termination | Waking earlier than intended & unable to resume sleep | ||
Severity | |||
Mild | Almost nightly complaint | little or no impairment on social or occupational functions | |
Moderate | Nightly complaint | Mild-moderate impairment on social/occupational functions | |
Severe | Nightly complaint | Severe impact on social/occupational functions |