Enhancing digital CBT-I to improve adherence and reduce disparities

项目摘要/摘要 失眠是一种使人虚弱的疾病，它会增加患各种疾病的风险，并影响多达三分之一的 成年人。虽然失眠可以通过认知行为疗法(CBT-I)有效地治疗， 缺乏接受过CBT-I培训的专业提供者。因此，大多数失眠患者都是 无法接受CBT-I作为推荐的一线失眠干预措施。为了解决这个问题， CBT-I现在可以以数字方式提供(dCBT-I)，具有很强的有效性；然而，现实世界中 DCBT-I受到参与度不高的限制。超过50%的患者没有完成dCBT-I的整个疗程，并且 坚持治疗的患者中有40%不坚持dCBT-I的关键成分。此外，治疗 在那些社会经济地位较低的人中，完成率和遵从性要差2-3倍。我们的飞行员数据显示 在完成和遵守dCBT-I方面的差异与低健康素养有关，健康素养的定义是 查找、理解和使用信息和服务，为与健康相关的决策提供信息。健康素养是 对于参与自我指导的数字干预特别重要，例如dCBT-I。 这项提案是对一项专注于提高患者对治疗的依从性的声明的回应。我们 提出大规模干预对比增强型dCBT-I在改善治疗中控制dCBT-I 在按社会经济地位分层的样本中完成和遵守。我们还建议测试一下 关于减少治疗依从性和完成率方面的社会经济差距的增强的dCBT-I。一个 这项试验的创新部分是使用非专业教练作为低健康素养的支架，以及 增强治疗动机和自我效能感。此外，那些面临接受治疗的风险的人 完成后转向远程健康指导，专注于为其量身定做的单个关键行为组件 易于融入患者的日常生活。自适应组件为患者提供了两种不同的 最大限度地提高参与度的治疗模式，这两种方法都利用技术来提高 可访问性。我们的长期目标是确保数字失眠治疗的公平有效性。到那时候 最后，我们的总体目标是确定如何改进dCBT-I的遵守和完成情况， 特别是在作为健康差距人群的SES较低的人群中。基于试点数据，我们的中心假设 与控制dCBT-I相比，增强型dCBT-I将通过提供有针对性的支持来提高参与度 为那些需要的人准备的。

PROJECT SUMMARY/ABSTRACT Insomnia is a debilitating condition that escalates risk of a myriad of disorders, and affects up to one third of adults. Although insomnia can be effectively treated with Cognitive Behavioral Therapy for Insomnia (CBT-I), there is a shortage of specialty providers trained in CBT-I. Consequently, most patients with insomnia are unable to receive CBT-I as the recommended first-line intervention for insomnia. To address this problem, CBT-I can now be delivered digitally (dCBT-I) with strong efficacy; however, the real-world effectiveness of dCBT-I is limited by poor engagement. Over 50% of patients do not complete the full course of dCBT-I, and 40% of those who persist in treatment do not adhere to critical components of dCBT-I. Moreover, treatment completion and adherence are 2-3 times worse in those with low socioeconomic status. Our pilot data indicate that the disparity in completion and adherence to dCBT-I is related to low health literacy, defined as the ability to find, understand, and use information and services to inform health-related decisions. Health literacy is especially critical for engagement with digital interventions that are self-guided, such as dCBT-I. This proposal responds to an announcement focused on improving patient adherence to treatments. We propose a large-scale intervention comparing enhanced dCBT-I to control dCBT-I in improving treatment completion and adherence in a sample stratified by socioeconomic status. We also propose to test the effect of enhanced dCBT-I on reducing socioeconomic disparities in treatment adherence and completion. An innovative component of this trial is the use of non-specialist coaches as a scaffold for low health literacy, and to enhance treatment motivation and self-efficacy. Furthermore, those who are at-risk for treatment non- completion are shifted to telehealth coaching focused on one single critical behavioral component tailored for ease of assimilation into the patient’s daily life. The adaptive component provides patients two different treatment modalities to maximize engagement and both approaches leverage technology to increase accessibility. Our long-term goal is to ensure equitable effectiveness of digital insomnia treatments. To that end, our overall objective is to determine how adherence and completion in dCBT-I can be improved, particularly in those with low SES as a health disparities population. Based on pilot data, our central hypothesis is that, compared to control dCBT-I, enhanced dCBT-I will increase engagement by providing targeted support for those who need it.