Using eHealth to Expand Access to Cognitive Behavioral Therapy for Insomnia in Hispanic Primary Care Patients

超过3000万美国成年人和近20%的初级保健患者患有慢性失眠症。慢性 失眠与发病率、死亡率和高经济成本相关，因此代表了一种 重大公共卫生问题。重要的是，西班牙裔美国人失眠的患病率明显较高， (26.5非西班牙裔白人（22.5%），这种差距随着时间的推移而扩大。认知行为 治疗失眠是一种强大有效的心理干预治疗失眠持续 好处，并建议超过药物作为一线治疗慢性失眠。不幸的是， 很少有人能得到这种标准的护理。西班牙裔，特别是那些英语水平有限的人，甚至 比非西班牙裔白人更不可能获得高质量的循证行为卫生保健 如CBT-I，主要是因为缺乏合格的双语行为提供者， 用西班牙语提供CBT-I和费用。考虑到拉美裔失眠症的发病率越来越高， 今天的行为保健工作队伍的语言现实，对双语行为健康的需求， 有能力以西班牙语提供CBT-I的供应商远远超过供应量。保健方面的进展 信息技术，如自我指导电子保健治疗，是一种创新和可扩展的手段， 解决使精神卫生保健差距永久化的供需不平衡问题， 在得不到充分服务的社区，执行工作仍然难以落实。事实上，CBT-I通过基于网络的在线 平台与CBT-I亲自交付的一样有效，但CBT-I现有的电子健康计划还没有 适用于服务不足的患者群体。此外，还提供了关于促进发展的障碍和促进因素的数据， 在服务不足的种族/少数民族人群中实施这些电子健康行为治疗， 很少收集或用于支持将其纳入初级保健。拟议的研究将使用混合试验 类型1有效性-实施研究设计和混合方法方法， 电子健康平台的技术进步，以（1）招募200名讲西班牙语的西班牙裔初级保健患者 将慢性失眠症纳入一项随机对照试验，比较文化适应的电子健康版本的有效性， CBT-I与增强的日常护理对减少失眠症状的作用;（2）同时评估 组织、患者和提供者的实施障碍;（3）确定 干预。通过利用电子保健的最新进展和利用互联网的日益增长的速度， 在西班牙裔美国成年人中使用，这项研究有可能扩大获得循证替代品的机会， 药物治疗慢性失眠症，并缩小现有的种族/民族差异， 为初级保健患者提供高质量的行为健康护理。

Over 30 million US adults and nearly 20% of primary care patients suffer from chronic insomnia. Chronic insomnia is associated with increased morbidity, mortality, and high economic costs, and thus represents a major public health problem. Importantly, the prevalence of insomnia is significantly higher in Hispanics (26.5%) than non-Hispanic Whites (22.5%), and this disparity is widening over time. Cognitive behavioral therapy for insomnia is a robustly effective psychological intervention for treatment of insomnia with sustained benefits, and is recommended over medications as the first-line treatment for chronic insomnia. Unfortunately, few receive this standard of care. Hispanics, and particularly those with limited English Proficiency, are even less likely than non-Hispanic Whites to have access to high quality evidence-based behavioral health care such as CBT-I, primarily because of the lack of available qualified bilingual behavioral providers trained to deliver CBT-I in Spanish and costs. Given the increasing prevalence of insomnia among Hispanics, and the linguistic realities of today's behavioral healthcare work force, the demand for bilingual behavioral health providers equipped to deliver CBT-I in Spanish significantly outweighs the supply. Advances in health information technology such as self-guided ehealth treatments represent an innovative and scalable means to address the supply and demand imbalance that perpetuate mental health care disparities, however its implementation in underserved communities remains elusive. In fact, CBT-I delivered via an online web-based platform is as effective as CBT-I delivered in-person, but extant ehealth programs of CBT-I have not been adapted for use among underserved patient populations. Further, data on the barriers and facilitators of implementation of these ehealth behavioral treatments in underserved racial/ethnic minority populations were rarely collected or used to support its integration in primary care. The proposed study will use a hybrid trial type 1 effectiveness-implementation study design and a mixed methods approach that leverages recent technological advances in ehealth platforms to (1) enroll 200 Spanish-speaking Hispanic primary care patients with chronic insomnia into an RCT that compares the effectiveness of a culturally adapted ehealth version of CBT-I with enhanced usual care on reduction of insomnia symptoms; (2) concurrently assess the organizational, patient, and provider barriers to implementation, and (3), determine the cost-effectiveness of the intervention. By leveraging recent advances in e-health and capitalizing on the increasing rates of Internet use among Hispanic US adults, this study has the potential to expand access to evidence-based alternatives to pharmacotherapy for the management of chronic insomnia, and to narrow existing racial/ethnic disparities in access to high quality behavioral health care for primary care patients.